Taking budget constraints into account, you are asked to 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’smain campus teaching hospital emergency department and three freestanding remoteemergency departments. There are about 100,000 emergency encounters each yearfor the group and the four departments. The 40 physicians work an equal number ofshifts during the year. For those 100,000 encounters, the group as a whole reports143,787 individual CPT codes on claims in a year. Of those, 103,852 are evaluationand management codes (from 99281-99292); 28,093 are ECG interpretations (93010);the remaining 11,842 codes represent non-evaluation and management servicesdistributed throughout CPT and HCPCS. The group employs four certified coders(AAPC CPC©) who abstract the dictated encounter notes and code the encounters forclaim 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 servicethan was rendered; Coding/billing for services not rendered; and Coding/billing formedically unnecessary services;Credentials of auditing staff;Use of a random or a focused audit (i.e. x encounters per coder per month randomlyselected 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.