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Annual audits have certainly become commonplace for medical practices these days. While some practices perform their audits utilizing internal staff, others hire third-party firms. Of course, either method is acceptable if the individuals, whether internal or third-party, are trained auditors with experience to back up their credentials. But what should you expect from an audit? 

Most have been through this exercise enough to know that you will receive a spreadsheet noting the patients audited, the findings, and a detailed overview indicating what improvements should be made – we all know these expectations of the standard audit. But, based on the purpose of the audit, what are your own unique expectations? 

Over the years we have audited thousands of medical records, and met with practices and providers as part of the process. Invariably, we are often up for a fight when reviewing the audit findings, and this is understandable for providers frustrated by the documentation process that is the core of healthcare, as opposed to patient care, these days. However, this is inadvertently creating audits that often judge what a provider could defend, appeal (and potentially win), or even get away with (as opposed to achieving sufficient documentation preventing the need to defend, appeal, or “get away with” anything). As auditors working on behalf of practices, it is our job to understand our role within the compliance framework of the organizations we serve, remaining cognizant of the potential fallout of our findings, and to stand fast in creating documentation that won’t just get us by, but will maintain the integrity of the entire system. 

To begin consideration of these expectations, let’s first address the rules relating to documentation. The first rule is that most of our rules are not actually rules, but rather statements in need of interpretation, or guidelines from which one can draw conclusions. Within the audit process, it is critical that the auditor indicate whether deficiencies being revealed are being evaluated through the lens of provider opinions or actual rules.

Ironically, coding, billing, and even auditing are the areas that impact the bottom dollar most for any organization, but they also hold the most staff that are OJT (on-the-job-trained) as opposed to being formally trained, which over the years has led to “opinions” becoming the “gospel truth” in many practices. We must separate fact from fiction as it pertains to billing rules and guidance in healthcare, and our audits are a great place to do this. As an auditor, when you are performing an audit, you need to have a cited source ready to use for educational purposes to support your findings – not just your experience, knowledge, and opinions, as often these can be tainted. As a provider, you should question the auditor, the consultant, or even the carrier who is indicating that deficiencies exist within your documentation, and request cited sources to review for authentication. I think this is best explained through a simple example of chief complaint. The Centers for Medicare & Medicaid Services (CMS) has indicated that the chief complaint should be “in the patient’s own words,” but it has offered no additional advice or examples as to what they mean – so it is a statement from which individuals are free to draw their own conclusions.

An attendee at a recent event told me that their practice had recently underwent an audit by an outside third-party reviewer for compliance, and the reviewer had deemed all of their records as non-billable because the chief complaint was not in quotes, indicating that it was in the patient’s own words. Is that fact or opinion? I would argue it is opinion, and that it is making documentation guidelines more stringent than they were truly intended to be. Opinions about such vague statements within the guidelines should rather be more explicit, considering the purpose of such a statement.

Do we really think that CMS wants the patient “quoted,” or is the purpose to suggest that since the chief complaint centers on why the patient came to the office today, the provider should document the signs/symptoms of the patient (burning and frequency upon urination) as opposed to simply diagnosing the patient (UTI)? The auditor is tasked with voicing opinions that can be substantiated based on best documentation practices, sound advice, and what makes sense for patient continuity of care; the provider is tasked with asking the auditor to provide relativity to their opinions and interpretations to be sure that the advice is not too much of an extreme corrective action.

Within your audit, you should be able to expect audit findings that are based on facts and sourced – or demonstrated by opinion/interpretation that have sound, credible reasoning. 

About the Author

Shannon DeConda founded the National Alliance of Medical Auditing Specialists (NAMAS) eight years ago while working as a senior auditor for its parent organization, DoctorsManagement, a national auditing certification program. There she began a grassroots effort to educate and certify professionals. Today, NAMAS is committed to training medical auditors and investigators, and also committed to the continued education of those auditors and investigators in the industry.

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