Audit Support and Compliance Services

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THE NEED: With the countless challenges that impact healthcare providers today, it has never been more crucial to properly and sufficiently document in order to satisfy reporting requirements for E&M visits, procedures, supplies and other medical and ancillary services that your organization provides. The 2021 and more recent 2023 updates to the AMA’s CPT and to CMS’ billing requirements make this area important and timely.

HOW WE HELP: ArchProCoding performs thousands of documentation and coding reviews each year. The reviews we perform encompass Evaluation and Management (E&M) services and the other applicable aspects of coding and billing for providers in Rural Health Clinics (RHCs), Community Health (FQHCs), Critical Access Hospitals (CAHs), and small rural hospitals.  ArchProCoding offers a number of audit strategies based on the individual client’s situational needs.

WHAT WE DO: Considering the massive 2021 and subsequent 2023 updates to the CPT and CMS rules around how to document and report your services – now is the time to use your actual progress notes to help educate your clinical providers of their responsibilities, capturing complete and timely documentation and reporting their codes to the revenue cycle team.  In our experience clinical providers gain more insight and awareness of the complicated rules when they learn about coding and billing from their own notes, as opposed to a traditional training setting only.  In combination – training and audits provide a full circle approach that is sure to help you “Learn More to Earn More”.

The typical E&M audit/review process for each provider reviewed includes a selection process of 10-20 encounters typically selected for each provider. We suggest a sample reflecting a wide array of services that represents the full variety of services you provide (e.g., new patients, established patients, preventive medicine, minor procedures, annual wellness visits, etc.). 

For hospital audits, we suggest a select number of records, typically 10-20 encounters based on the service type, such as Inpatient/Swing Facility, Observation Facility, ED Facility and/or ED Professional Fees, Hospital or Swing Bed Professional Fees, Same Day Surgery, Outpatient/Ancillary, Ambulance, etc.

Documentation for each case will be carefully considered as described below:

  • For categories of E&M based on the service location of the patient, reviews will be performed assuming that medical necessity (i.e. medical decision making) or time will be the overarching criterion selection for each level of service.
  • The accuracy of CPT/HCPCS-II modifiers (e.g., -25, -59, -CG, XS, etc.), where applicable
  • The accuracy, specificity, and assignment of principle/first listed and other supportive ICD-10-CM codes
  • Following the audit, an executive summary and completed audit template is forwarded to the client for each provider reviewed, which demonstrates coding accuracy rates and applicable findings related to the review.
  • Provider and staff education, typically around 30 minutes per provider for  E&M audits, or up to one hour per hospital is arranged following the review to assist with corrective action and any questions the provider and or coding staff may have.

WHAT WE NEED FROM YOU:

  • HIPPA-compliant Business Associate Agreement (BAA) must be executed before the dissemination of any Protected Health Information (PHI) to adhere to HIPAA and HITECH requirements.
  • ArchProCoding uses a HIPAA-compliant Citrix service called ShareFile that is used for the transfer of electronic health records and all documents containing protected health information (PHI). Account access is assigned once the scope of service agreements are executed.
  • A pre-populated Microsoft Excel spreadsheet will be forwarded to you to enter the patient demographic information and the specific CPT/HCPCS-II/ICD-10-CM codes that were reported by the provider (or staff).

  • The data is reviewed by our experienced audit team and following the generated report, a time will be set for provider training and/or questions and can be provided virtually or in person.