Outpatient Surgery Magazine

Heavy Duty - October 2016 - Subscribe to Outpatient Surgery Magazine

Outpatient Surgery Magazine, providing current information on Surgical Services, Surgical Facility Administration, Outpatient Surgery News and Trends, OR Excellence and more.

Issue link: http://outpatientsurgery.uberflip.com/i/736989

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Page 45 of 126

tive reviews help make sure that the claims you file have the required documentation, are appropriately coded and comply with payer rules. As far as how many claims to audit, we suggest using the Office of Inspector General's recommendation. The OIG recommends 3 meth- ods for drawing random samples for your audit. Those methods include paid claims, claims by payer or claims including the top denials by payers. Paid claims are the largest group and contain all those where the payer has reimbursed you for the procedure. Claims by payer means selecting a random sample of claims from a specific payer to audit. Finally, you can audit a sample of all claims contain- ing 1 of your top 10 denials from your payers. The OIG recommends choosing at least 5 medical records per payer, or 5 to 10 medical records per physician to audit. Assign an auditor Assign a single individual to be in charge of the audit. This per- son can be one of your top coders or your billing manager. She should know the codes for various procedures and be able to check that pay- ers are reimbursing claims in accordance with your contract terms. This person should also compare how frequently you're performing certain services over a specific time period to the latest industry benchmark data. Analyze the claims When it's time to start checking the claims against the physician documentation and payer contracts, it's a good idea to create a check- list. This checklist should include confirming that the correct codes were used, that the physician documentation was correct and specific enough for ICD-10 codes, and that the claims are compliant with the payer's policies, including its agreement for the specific definition of 4 5 Coding & Billing CB 4 6 • O U T PA T I E N T S U R G E R Y M A G A Z I N E • O C T O B E R 2 0 1 6

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