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How to Complete a Coding Audit (Internal Medicine)

Correct coding by physicians is critical to getting paid for what you do and for avoiding external audits by Medicare and other payers. ACP has many resources on the issue. For a basic guide to evaluation and management (E/M) coding, go to the ACP Practice Management Center (PMC).

To better understand how your coding pattern compares to that of your peers, try PMC’s quick calculator E/M Coding Assessment Tool.

Ultimately, however, the only way to determine whether coding is appropriate is to compare it against the actual clinical documentation you recorded in the chart. This coding audit can reveal whether any variation from national averages is due to inappropriate coding or to atypical levels of intensity among your patients. Such a self-audit can help you make corrections before payers challenge any inappropriate coding, or it can give you the confidence to fully code the more intense encounters that you are conducting. Additional discussion of coding audits and corrective measures may be found in the July/August ACP Observer article entitled, ”Investing in an audit can reveal costly coding errors”.

If you have determined that you would like to pursue a coding audit, there are a few simple rules to consider to make sure that the audit demonstrates what you intend it to demonstrate. For the internist, the issues of coding are generally related to evaluation and management so this guide refers to evaluation and management auditing.

Rule #1: Select charts randomly.
Physicians rarely achieve a random sample by selecting the charts to be audited themselves. Don’t taint your sample by choosing the charts yourself. Ask a staff member to pull a patient list for a week, and pull every 5th chart until reaching 10 charts. It does make sense to concentrate on visits that took place at a certain time so that you can observe trends. Merely pulling charts at random out of the racks will not accomplish this goal. Avoid selecting specific charts by selecting charts randomly from a specified time period.

Rule #2: Don’t review your own charts.
It is nearly impossible for a physician to complete an unbiased review of his own charts. He can read his own handwriting perfectly; he can fill in gaps based on his typical thinking; and he might give credit for things that are not well documented. Remember that the person reviewing your charts if you ever actually get audited by an external payer will be unfamiliar with your penmanship, work style, and overall practice pattern. The person in your practice chosen to review the charts should certainly have knowledge of the coding rules, should be able to complete an auditing worksheet, and have a strong understanding of medical terminology. That person may be another physician, a nurse, a qualified coding specialist in the office, or a consultant hired for the purpose.

Rule #3: Use the same rules as the auditors.
Medicare and private insurer auditors may interpret guidelines in different ways, but they do usually stick to a few simple rules. First, they are supposed to use whichever E/M documentation guidelines that are more beneficial to the physician when auditing – either the 1995 or the 1997 guidelines. It is best for internists to start with 1995 guidelines as they are much more likely to benefit the internist. See ACP’s basic coding guide for more information on the difference between the 1995 and 1997 guidelines.

ACP members can find an auditing worksheet at ACP’s website.

Rule #4: Keep coding audits results professional and educational.
Physicians should be given the opportunity to review and study the results of their coding audits and to openly discuss what can be improved. Improved coding is encouraged when everyone on staff is committed to the goal of complying with documentation guidelines in order to avoid potential adverse impact on the practice. Avoid a heavy-handed response to the chart audit results -- making coding audits punitive for the parties involved does not benefit the practice and can lead to defensive behaviors that are even more harmful than simple miscoding.

Rule #5: Work at correcting errors.
Completing a coding audit accomplishes very little unless a serious effort is undertaken to fix the problems that are identified. Establishing an on-going reporting and feedback system to physicians is important. Error rates should be recorded, but trends in documentation should also be noted. If one physician is not documenting a thorough history, that should be noted. If another physician is not recording chief complaint, that should be improved. If the practice or the physician can show improvement from one quarter to the next, that is an excellent sign of commitment to fixing errors. Remember, correcting any systematic under coding uncovered in an audit will enable you to collect the revenue to which you are entitled, and addressing over coding will minimize the likelihood that you will have to pay money back to Medicare or another payer if audited.

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