Create an Internal Presubmission Code Audit Program for Compliance Purposes

The practice is a 40-physician emergency medicine group employing all board certified
(ACEP) emergency medicine physicians. The group is contracted to staff the hospital’s
main campus teaching hospital emergency department and three freestanding remote
emergency departments. There are about 100,000 emergency encounters each year
for the group and the four departments. The 40 physicians work an equal number of
shifts during the year. For those 100,000 encounters, the group as a whole reports
143,787 individual CPT codes on claims in a year. Of those, 103,852 are evaluation
and management codes (from 99281-99292); 28,093 are ECG interpretations (93010);
the remaining 11,842 codes represent non-evaluation and management services
distributed throughout CPT and HCPCS. The group employs four certified coders
(AAPC CPC©) who abstract the dictated encounter notes and code the encounters for
claim submission.
Taking budget constraints into account, you are asked to create an internal presubmission code audit program for compliance purposes. Detail your
proposed plan.
Consider all of the following elements for your plan:
Sample Methodology (by coder? by physician?);
Timing (monthly, quarterly, annually?);
Scope (all services? E&M only? Some combination?)
Number of encounters in sample;
Goals of the plan;
Inclusion of key areas of concern including: Coding/billing for a higher level of service
than was rendered; Coding/billing for services not rendered; and Coding/billing for
medically unnecessary services;
Credentials of auditing staff;
Use of a random or a focused audit (i.e. x encounters per coder per month randomly
selected vs. x 99284 codes reported per physician per month).
What, if any, comparables you would use and where you would find them.
How you would report your findings;
To whom you would report your findings;
Follow-up plans based upon the findings