3 Solutions to the Most Common Auditor Mistakes

Auditing is hard work and requires a special kind of personality and superhuman attention to detail. We know that it’s tedious to keep coders, physicians, and everyone at your organization marching to the same beat. And, we understand that, despite experience or intentions, mistakes and oversight happen.

A lot of the mistakes that we come across while we’re out in the field auditing, auditors, are common and occur frequently. Most often, this is due to ambiguous rules or common misconceptions regarding certain situations. Luckily, these common mistakes are easily preventable with a few simple solutions.

3 Solutions to the Most Common Auditor Mistakes

1. Mistake: Forgetting to Check the Data:

A common error that coders and auditors make is not giving credit for amount and/or complexity of data reviewed/ordered in the Medical Decision Making component of an evaluation and management service.

Solution: Credit should be given for labs that are reviewed/ordered, X-rays reviewed/ordered, and/or injections of medication ordered. If history is obtained from someone other than the patient (caregiver, family member, etc), credit should be given. If the provider discussed the case with another provider (specialist, radiologist, etc) during the encounter, credit should be given. All of this data is important when calculating MDM.

2. Mistake: Miscalculation of Exam Patient Risk:

Auditors sometimes perceive a lower MDM (medical decision making) complexity than the documentation supports, when the established problems are stable or improving. This is especially noticed in the inpatient setting. For example, a patient who is diagnosed with sepsis or acute respiratory failure, who also has hypertension, anemia, and diabetes, all being managed by the physician.

Solution: For a subsequent visit when the physician documents “some improvement,” it does not mean that the MDM is no longer high complexity. The patient still has sepsis or acute respiratory failure which places them at high risk. Even if all four established problems are improving, high complexity MDM is still supported based on the audit guidelines.

3. Mistake: Diagnosis Codes (Audits):

Sometimes, auditors will not perceive a diagnosis as being supported if there is not an entry of some type stating the condition is specifically addressed at the visit.

Solution: The ICD-10 guidelines for outpatient services state, “Code all documented conditions that coexist at the time of the encounter/visit, and require or affect patient care treatment or management.” There are multiple conditions that impact other conditions, so it’s appropriate for the physician to report all of the codes. A patient with multiple chronic conditions is at higher risk, and many conditions can impact treatment for other conditions. For example, a patient who presents with an open wound who also has diabetes, is at a higher risk due to slower healing and/or fluctuation of blood sugar levels. It is important for both diagnosis codes to be assigned because diabetes impacts the treatment for the wound. Another example is that the risk for stroke increases for patients with atrial fibrillation who also are diagnosed with history of congestive heart failure, hypertension, diabetes, previous stroke, or are 75 years old or older.

Download our short eBrief, "7 Common Mistakes That Auditors Make," for a full list of solutions to the most common auditor blunders.