Outpatient Auditing Compliance

Outpatient auditing and compliance review of medical coding are essential components of healthcare management, ensuring accurate coding of medical services, adherence to regulatory guidelines, and overall compliance with established standards.

With the increasing reliance on overseas medical coding, which often has a higher error rate than domestic coding, the need for outpatient auditing has become even more crucial.

Along with inpatient and physician auditing and compliance services, Coding Billium (CB) specializes in this critical auditing function and can help your organization avoid financial penalties, loss of reimbursement, legal issues, and reputational damage caused by inaccurate coding.

Why Is Outpatient Auditing & Compliance So Important?

Outpatient auditing and compliance play a crucial role in medical billing, ensuring the accuracy, integrity, and legality of healthcare financial transactions. Due to the complexity of healthcare billing and the potential for errors or fraudulent activities, auditing and compliance measures are essential to maintain the integrity of the billing process.

One primary reason outpatient auditing is vital is to ensure accurate reimbursement for healthcare services. Billing errors can lead to underpayment or overpayment, affecting the financial health of healthcare providers. Regular audits help CB clients identify and correct coding discrepancies, documentation issues, and other billing errors that may lead to financial losses.

Compliance in outpatient services is equally important to adhere to regulatory standards and guidelines set by governmental bodies such as the Centers for Medicare & Medicaid Services (CMS), private payers, the ICD (International Classification of Diseases) coding regime, and the CPT (Current Procedural Terminology) system.

Additionally, compliance with HIPAA (Health Insurance Portability & Accountability Act) is essential to protect patient privacy and ensure the secure handling of health information. Non-compliance can lead to severe penalties, fines, and legal consequences. CB stays up to date with the latest regulations, ensuring compliant billing practices to avoid legal ramifications and maintain a strong reputation.

Outpatient auditing also helps prevent and detect fraudulent activities, which can be detrimental to both healthcare providers and patients. CB‘s outpatient audits identify billing pattern irregularities or coding practices that could help mitigate fraud risks, protect patient data, and ensure appropriate resource allocation.

The CB Auditing Process

When performing an outpatient audit, the expert consultants at Coding Billium follow a detailed and comprehensive review process. The following are the key steps involved:

• Review your team’s skill level in ICD-10-CM and CPT.
• Analyze claims data to target specific areas for focused audits.
• Evaluate the appropriateness of ICD-10-CM diagnosis coding.
• Assess HCPCS/CPT procedure code selection, facility evaluation, and management (E&M).
• Determine the completeness of documentation to support appropriate coding assignment.
• Validate physician orders, NCDs, and LCDs concerning the medical necessity of services.
• Ensure the correct code transfer to claim forms and confirm that the correct APC payment is received on remittance information.

Avoiding Consequences of Non-Compliance

Inaccurate coding or failure to comply with regulations can lead to:

• Financial penalties
• Loss of reimbursement
• Legal issues
• Reputation damage

When you partner with Code Billium for outpatient auditing and compliance, you can be assured that your organization will adhere to best practices and regulatory standards.