Urgent care billing and coding audit

Recently, the significance of quality and safety in urgent care has increased, with a heightened emphasis on clinical outcomes and patient satisfaction. Despite these demands, the accurate documentation of medical records, the correct application of billing codes, and the precise invoicing of insurers are indispensable for the financial stability of urgent care practices. Health authorities and healthcare organizations have placed a strong emphasis on utilizing audits as a critical component of quality improvement (QI) strategies. This involves systematically evaluating care delivery, pinpointing areas needing enhancement, and instituting constructive changes to elevate the overall standards of urgent care services, reputation, and revenue.
However, any practice can implement auditing service accurately only when it knows deeply about its purpose and strategies to employ it in its urgent care department effectively. Therefore, we have mentioned all the necessary details about urgent care billing and coding audits so that you can navigate the complexities, prevent claim denials, and streamline revenue.

Mastering Urgent Care Billing and Coding Audits

Claim denial is a booming concern for any healthcare facility, and urgent care organizations are no exception. This claim denial can occur due to any minor mistakes, but majorly, it occurs due to errors in front desk operations such as inappropriate details, incomplete documentation, undocumented services, inaccurate coding, duplicate claim submission, errors in urgent care modifiers, etc. To escape this issue, an important step involved in urgent care RCM named auditing plays a crucial role.
An urgent care billing and coding audit is a systematic and thorough examination of the billing and coding processes within an urgent care facility. This audit evaluates the accuracy, efficiency, and compliance of clinical documentation, billing codes, and reimbursement claims submitted to insurance providers. The purpose of this audit is to identify discrepancies, errors, or inappropriate billing practices. During a coding and billing audit, the auditor gathers clinical documents like medical records, x-rays, and lab reports. They also examine financial records such as entered charges, explanation of benefits (EOBs), and accounts receivable ledger. Additionally, policy-related documentation mandated by providers or the government is reviewed as necessary. By conducting this evaluation, urgent care facilities can ensure proper reimbursement, compliance with healthcare regulations, and the integrity of their financial and operational systems.

Urgent care billing audit and its scope

Urgent care billing audits, also called "RCM audits," employ a thorough methodology that surpasses coding audits. They meticulously assess every facet of the billing life cycle, beginning with insurance verification, ICD-10-CM and CPT coding, claim submission, payment posting, diligent follow-up, and proficient denial management processes. The comprehensive procedure meticulously examines the health records within the practice and evaluates the medical billing information sent to payers. This ensures the practice effectively identifies, monitors, and corrects any improper billing practices, promoting accuracy and integrity in financial transactions.

Urgent care Coding audit & its purpose

An urgent care coding audit involves a meticulous examination of an urgent care facility's coding procedures, whether carried out internally or by external experts. This thorough review focuses on the patient's medical records, aiming to assess the accuracy and comprehensiveness of the selected procedural and diagnostic codes based on the physician's documented information.
Coding audits are essential because routine coding audits are vital in identifying outdated CPT codes from AMA, HCPCS codes from CMS, incorrect modifiers, improper code usage, and flaws within billing procedures. It also helps in preventing unbundling, upcoding, and downcoding.

When to conduct an urgent care coding audit?

The frequency of urgent care medical coding audits can vary based on several factors, including the size of the healthcare facility, the volume of coding performed, changes in regulations, and the facility's specific needs and risk tolerance. However, there are some general guidelines that healthcare organizations can consider when determining how often to conduct medical coding audits:

Regular Internal Audits: Conducting internal audits regularly, such as quarterly or semi-annually, is a common practice.
New Coders or Significant Workflow Changes: When there are changes in staff, processes, or significant updates in coding guidelines, it is advisable to conduct audits more frequently. Similarly, if there are substantial changes in the workflow or software systems, audits can help identify and address potential issues early.
Focused Audits: Conduct focused audits when there are specific concerns or identified problem areas. For instance, if a facility notices an increase in claim denials or coding errors related to a particular service, conducting a focused audit on that area can help pinpoint the problem and implement corrective measures.
Random Sampling Audits: Periodically conducting random sampling audits throughout the year can ensure ongoing compliance and accuracy. Random audits can catch issues that might not be detected through scheduled audits.

Urgent care billing and coding audit checklist

Patient record verification:

Verify basic patient details, including name, address, contact number, date of birth, and emergency contact information. Confirm the patient's insurance details, including policy number, coverage, and co-pays. Thoroughly review the patient's medical history, including past illnesses, allergies, medications, and surgical procedures. Implement identity verification measures, such as photo IDs or biometric scans.

Provider information verification:

Verify the provider’s information, including their credentials and National Provider Identifier (NPI) number. Cross-reference this data with the official records to confirm the authenticity of the healthcare provider.

Completeness of medical history:

Evaluate the medical history section of the patient’s record. Ensure that it is complete, including previous illnesses, allergies, medications, and surgeries.

Verification of diagnostic report:

Review diagnostic reports such as lab results, X-rays, and other tests. Verify that the reports are attached to the patient’s record and are accurately interpreted and documented.

Details of services provided:

Examine the details of services provided during the patient’s visit. This includes procedures, examinations, treatments, and medications administered. Cross-check this information with the medical records to confirm that all services are accurately documented.

Proper documentation:

Ensure that all services provided are adequately documented in the patient's record. Adequate documentation includes detailed notes on the patient's condition, examinations performed, treatments prescribed, and follow-up recommendations.

Accurate coding:

One of the most critical aspects of the audit is verifying the accuracy of the codes assigned to the services provided. Use current Healthcare Common Procedure Coding System (HCPCS) or S codes and 2023 CPT codes for urgent care billing and coding. Moreover, ensure that your codes are implemented according to urgent care billing CMS guidelines.

Compliance Assessment:

Verify compliance with healthcare regulations, such as HIPAA (Health Insurance Portability and Accountability Act) and other federal and state laws. Ensure that patient privacy and confidentiality standards are maintained.

Importance of Urgent care billing and coding audits: Exploring the benefits

Reduced billing errors & claim denials

One of the foremost benefits of conducting regular billing and coding audits is the significant reduction in billing errors. These errors can range from simple mistakes, such as data entry errors or incorrect coding, to more complex issues like unbundling of services. By identifying and rectifying these errors, urgent care facilities can ensure accurate billing, which is essential for maintaining the trust of patients and payers.
Audits play a pivotal role in reducing claim denials by ensuring that claims meet all necessary criteria for approval. By identifying and addressing coding issues, such as using the correct modifiers, verifying the medical necessity of services, and adhering to payer-specific guidelines, you can significantly decrease the likelihood of claim denials.

Increases profitability

The audit identifies inaccuracies, errors, and loopholes in effective urgent care billing. When these issues are identified before submitting a claim, the billing and coding team addresses these issues to prevent claim denials and, hence, increase reimbursement.

Better Compliance

Ensuring adherence to regulations is the primary motivation behind urgent care billing & coding audits. These coding audits demand strict compliance with diverse entities, including payer policies, Medicaid, Medicare, and the Office of the Inspector General (OIG), among others. Through these audits, healthcare providers identify coding discrepancies, paving the way for corrective actions and novel prospects.

Protection against Fraud and Abuse

In the urgent care industry, billing fraud and abuse are significant concerns. Unscrupulous billing practices can lead to severe consequences, including losing medical licenses and legal repercussions. Regular billing and coding audits help detect and prevent fraudulent activities, protecting the reputation and integrity of your urgent care center.

Positive Reputation

Efficient billing and coding practices contribute to the positive reputation of urgent care facilities. Patients trust facilities that provide transparent and accurate billing, leading to increased patient loyalty and positive word-of-mouth referrals.

Types of urgent care billing and coding auditing

Internal auditing:

These audits, conducted by internal urgent care facility auditors such as quality officers or healthcare professionals from unrelated departments, ensure unbiased assessments. Healthcare entities utilize these internal audits to elevate the standard of care consistently. By evaluating and enhancing the effectiveness of the organization's quality management system, these audits concentrate on organizational conditions, fostering a culture of continuous improvement.

External auditing:

External auditing is conducted by independent third-party organizations or professionals specializing in healthcare compliance. External auditors bring expertise and industry benchmarks, offering valuable insights into your facility’s performance.

Prospective:

Prospective auditing involves the real-time review of coding and billing documentation before claims are submitted. Cases for prospective audits are often selected based on Office of Inspector General (OIG) guidelines or high-risk areas identified in previous external audits. By scrutinizing medical records and coding assignments before claims are filed, urgent care facilities can prevent errors and inaccuracies from affecting reimbursement.

Retrospective:

Retrospective auditing, on the other hand, occurs after claims have been submitted, processed, and mainly adjudicated.

Tips to implement effective urgent care billing and coding auditing

Educate your staff:

Knowledgeable and well-trained staff are your best assets in billing and coding auditing. Continuous training for your billing and coding staff is critical to staying updated with the ever-changing healthcare regulations. Conduct regular workshops and seminars to enhance their knowledge about new codes, compliance requirements, and documentation best practices.

Implement checklist:

Implementing checklists tailored to urgent care services can significantly enhance the auditing process. Create detailed checklists covering various aspects of billing and coding, ensuring all codes, modifiers, and documentation requirements are included. Regularly update these checklists to align with industry changes and updates.

Create clear auditing policies:

Setting clear and concise auditing policies is the cornerstone of an effective billing and coding auditing process. Outline guidelines for code selection, documentation requirements, and compliance standards. Clearly define roles and responsibilities within your billing and coding team to avoid confusion.

Leverage Technology:

Invest in reliable billing and coding software equipped with real-time error detection features. Implement electronic audit tools, NCCI audits, HER to streamline the process. Automation can help flag potential issues before claims are submitted, minimizing the chances of denials and rejections.

Outsource to Professional Auditing Services:

Consider outsourcing your billing and coding audits to professional healthcare auditing firms. These experts have in-depth knowledge of industry regulations and can conduct comprehensive audits, ensuring maximum compliance and revenue optimization.

Unleash the Power of Expert Auditing with MedsIT Nexus: Elevate Your Urgent Care Billing Experience!

Are you tired of juggling the complexities of medical billing and auditing while trying to focus on providing top-notch patient care? MedsIT Nexus Urgent Care Billing Company is your ultimate solution. We are not just a professional auditing service; we are your partners in ensuring the financial health of your practice. Our dedicated team of auditors meticulously reviews your records, identifies discrepancies, and ensures compliance with industry standards, leaving no room for errors. We conduct regular auditing using cloud-based billing software, practice management software, and electronic health records while adhering to HIPAA guidelines to protect PHI. Join hands with us, and let's embark on a journey towards financial excellence and operational efficiency.