Tips to Consider When Performing a Self-Audit
To avoid a possible error, providers should ensure they are billing the appropriate code for the service(s) being billed. We encourage you to conduct self audits to identify coverage and coding errors. A few tips to consider:
- Make sure level of service is determined by the care rendered, and not by volume of documentation.
- Does the documentation support the level of service reported?
- Does the documentation include evidence of a face-to-face visit when appropriate?
- Is it clear who performed the work?
- Make sure all documentation is legible?
- Have all records been signed (handwritten or electronic)?
- Are all orders documented and signed?
- Are all lab results in the patient's chart?
Remember: Medical necessity is the primary criterion for payment of statutorily covered services.
For determining the appropriate E&M code, providers are encouraged to review CGS Online Education Center modules (a series of 3) on Evaluation & Management visits.