Many providers are aware that CMS has increased its RAC audits and commercial payers are also taking a closer look at billing and coding usage.

Data analytics usage has enabled payers to identify coding and other “outliers” and in turn, track for audits. With a stated goal of recovering over $2 billion in “improper payments,” it’s more critical than ever for practices to be in compliance. These audits can have a negative impact on their bottom line.

Here are some tips to minimize the exposure to a RAC audit.

1. Ensure Accurate Medical Coding

A practice is a target for a RAC audit if a medical service is coded incorrectly and that service is reimbursed by Medicare or Medicaid. Monitoring coding activities on a regular basis can eliminate auditing as well as safeguard revenue.

2. Conduct Internal Audits

Conduct an internal audit of the coding and billing department or billing service vendor at least once annually. Coding mistakes can happen due to inadequately trained staff. Make sure that the staffs are properly trained. Over coding can pose a threat of an audit.

3. Avoid Copy-pasting

The documentation regarding patient details and illness information must be patient-specific, and should not be copy-pasted from the previous visit if it has no relevance to the problem. This copy-paste could result in wrong information that is no longer relevant, confusing and can result in coding errors. Mistakes in documentation can violate HIPPA rules and expose the physician to the risk of fraud and malpractice charges.

4. Never Over-rely on Automated E&M Coding Feature of EHRs

EHRs can automatically assign E&M codes, but they are particularly weak when it comes to medical decision making. The hidden danger is that EHRs automatically guide the physicians to create records that document high levels of care which results in an increase in the percentage of claims with level-4 and level-5 codes. These higher level codes are a prime RAC target. So it is better not to rely completely on the EHR’s code-selection engine to assign codes for E&M services.

5. Medical Necessity Documentation

Whenever a specific test or procedure is ordered, the medical necessity behind this order must also be documented. The Office of the Inspector General (OIG) feels that sleep studies, MRIs, and outpatient physical therapy services are over-utilized, so ensure comprehensive documentation for these.

6. Compare E/M codes averages to a Benchmark

Evaluation and Management (E/M) codes are well-known targets for external audits. Physicians who over-code evaluation and management services (E&M) relative to their peers are more prone to the risk of audit. The key to comparing E/M codes ave

rages to a national benchmark. If the result is different from that of their peers, physicians stand a greater risk of being exposed to an audit.

A RAC audit can mean a heavy financial burden on providers as it results in administrative expenses for coordinating requests and legal processes.

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