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Knowledge center

Did You Know?

The Forgotten Component of a Level IV E/M Decision Making

Many providers easily remember prescription drug management or recommending an elective surgery as the third component of MDM for a 992X4 E/M. However, the most commonly forgotten risk listed under moderate risk of morbidity from additional diagnostic testing or treatment is “Diagnosis or treatment significantly limited by social determinants of health”. AMA has published Evaluation and Management (E/M) Services Guidelines and defines social determinants of health as: “Economic and social conditions that influence the health of people and communities. Examples may include food or housing insecurity.” (pg. 18).

view the AMA evaluation and management guidelines here

did you know?

A chief complaint is required in visit documentation, for all but a preventative visit.

Ensuring all services are supported and all appropriate revenue is captured

Educating providers on documentation guidelines

Reviewing quality of care provided to patients

the Importance of Audits in a Practice, as quoted by AAPC:

Defending against external audits, malpractice litigations, and health plan requests and denials

AAPC CPMA Certified Professional Medical Auditor Study Guide. 2024th ed., AAPC, 2024. p. 1.

Yes!

“A Recovery Audit Contractor (RACs) review claims on a post-payment basis and use the same CMS regulations that providers are required to follow.” If the RAC discovers improper payments they will notice the Medicare Administrative Contract (MAC) who will adjust the claim or send a demand letter for overpayment.
This all started back in 2005 and ran through to 2008, when the Medicare Modernization Act, Section 306 required a three-year Recovery Audit. “Auditors identify overpayments and underpayments made to healthcare providers and suppliers submitting claims…” This three year audit “resulted in excess of $900 million in overpayments recovered and nearly $38 million in underpayments returned…”.

As a result, we now have a RAC Audit Process.

The reason you should track the frequency of RAC audits is to identify your level of risk. If you discover an increased number of audits, you should consider conducting an internal coding audit.