Self Audit: The New Quarterly Exam Self Audit: The New Quarterly Exam

Self Audit: The New Quarterly Exam

Karen House, CPC, CEMA

This auditing and compliance “Tip of the Week” was originally published by the National Alliance for Medical Auditing Specialists (NAMAS), a division of DoctorsManagement.

Are you an office manager who doesn’t check the provider’s notes or coding on a regular basis? If your answer is yes, that could put your practice in a vulnerable place. Every conference emphasizes it’s not IF you will get audited; it’s WHEN. Most providers and office managers are in fear of an audit, with good reason. There are benefits to having a self-audit done before an insurance company comes looking for money they can recoup.

Can I get a raise?

Undercoding is a large problem. I am sure that voice in your head is saying “let’s just stay under the radar with Medicare and other insurances.” That fear will cause providers to undercode, most of the time, staying in the middle with a 99213. There are a lot of times when a 99214 could be billed. The result is a loss of revenue to the practice that could amount to thousands of dollars. This also undervalues the work and time put in by the provider.


Was extra time spent with a patient and not documented? Accurate documentation of time spent with a patient can also boost revenue. If the additional time spent with patients is for counseling and/or coordination of care, you can bill the E/M code based on time, or utilize the extended time, counseling, and chronic care management C.P.T. codes, BUT your documentation must have:

  • Total time of the visit
  • Time or percent of the visit spent in counseling and/or coordination of care
  • Nature of the counseling and/or coordination of care

With patients having more and more complex medical problems, there may be more time spent with complex patients than normal. Be aware this could add revenue.

Where’s the Beef?
With a self-audit, the practice may be able to see where issues exist in collecting money. Is it the provider not coding correctly? Is it a disorganized front office? Is it a billing or collection specialist not staying on top of the accounts receivable…or is it all of the above? Professional auditors and practice management specialists say they look for, and often find, weaknesses in the way providers chart and in the way practices file claims and pursue collections, such as:

  • Poorly documented E/M codes
  • Incorrect physician practice ID numbers or patient IDs on the claim
  • Inaccurate use of CPT modifiers, or lack of use
  • Lack of understanding about how the insurer defines medical necessity
  • Lack of follow-up by staff when claims remain unpaid
  • Billing for non-covered services
  • Weak collection of patient co-pays, co-insurance, and unpaid balances
  • Coding nearly every office encounter as equal in complexity
  • No documentation regarding reasons for lab tests and other ancillary services
  • No attempt to write an OIG compliance program
  • Failure to bill incident to services provided by physician extenders under the physician’s code, if appropriate, to increase payment level
  • Lack of coding to separate out extra services that might add additional revenue
  • Few formal reviews of explanation of benefits forms to understand why claims were rejected
  • Insufficient documentation to back up either CPT or diagnostic coding
  • Inadequate use of ‘scrubbing’ software to check the completeness of superbills

By allowing a practice management specialist and/or a professional auditor to advise you on making the practice run more efficiently, everyone could be in a win-win situation. A happy office manager makes for a happy provider.


This Week’s Audit Tip Written By:

Karen House, CPC, CEMA

Karen has been in the healthcare industry for more than 20 years. Starting as a teenager in high school filing papers in charts, she worked her way up to the front desk, billing, and eventually office management. She currently serves as a Medical Billing and Coding Supervisor for Associates in Family Practice in Maryland. Karen’s experience spans from Urology, Orthopedics, Orthopedic Spine, Physical Therapy, Pain Management, to General Practice -and even Medical Software. She enjoys helping providers and their office staff run efficiently and ultimately get back to patient care

What to do next…

  1. Contact us to discuss your audit needs by calling (800) 635-4040 or email
  2. Read more: What can you expect from a coding and compliance review?
Here’s why thousands of providers trust DoctorsManagement to help improve their coding and documentation.

Quality of coders and auditors. Our US-based auditors receive ongoing training and support from our education division, NAMAS (National Alliance of Medical Auditing Specialists). All team members possess over 15 years of experience and hold both the Certified Professional Coder (CPC®) as well as the Certified Professional Medical Auditor (CPMA®) credential.

Proprietary risk-assessment technology – our auditing team uses ComplianceRiskAnalyzer(CRA)®, a sophisticated analytics solution that assesses critical risk areas. It enables our auditors to precisely select encounters that pose the greatest risk of triggering an audit so that they can be reviewed and the risk can be mitigated.

Synergy – DoctorsManagement is a full-service healthcare consultancy firm. The many departments within our firm work together to help clients rise above the complexities faced by today’s healthcare professionals. As a result, you receive quality solutions from a team of individuals who are current on every aspect of the business of medicine.