Standardizing Audit Feedback to Enhance the Outpatient Educational Process

Lynn Thornton, RHIA, CCS

MedPartners Education and Compliance Manager

outpatient educational process


There is no doubt the auditing process is a valuable endeavor that helps drive correct coding, optimize reimbursement and satisfy coding compliance efforts. It also serves as an excellent source of coding education. However, the auditing process does not support the educational effort if feedback to coders on identified errors is insufficient or ambiguous. Sufficient documentation is necessary to support an identified addition, deletion and/or change of a code or modifier. The specific documentation used to support a coding change must be referenced in the audit feedback as well as the official source of coding guidance.

One coding competency that is often inadequately documented for educational purposes is the rationale for modifier changes. It is an ineffective educational process to provide overly simplistic audit feedback that states, “Add modifier RT”, “Add modifier LT”, and/or “Add modifier 50”. It is far more educationally effective to provide the coder with guidance for determining if these modifiers are appropriate for a given CPT code.

This may be accomplished by referring the coder to the Medicare Physician Fee Schedule (MPFS) BILT SURG (Bilateral surgery) indicator and providing a concise statement that supports the modifier addition and/or deletion. Not all modifiers may be validated on the MPFS and thus solid research must be completed insofar as when and why modifiers are applicable.

To that end, the audit team would benefit by having a standardized set of audit feedback they may copy and paste into their audit document that is in reference to any identified error. This would assist the auditors by speeding up the audit process, providing complete/concise education and it also affords them the opportunity to spend additional time in researching subject matter in which they are uncertain. Examples of typical audit statements are included in the table below.

Standardized Audit Statements Error In Appending Modifier RT (Right Side): Per the CMS MPFS, this code has a BILT SURG (Bilateral surgery) indictor of (0) = Not allowed. Modifiers LT (Left side), RT (Right side) and/or 50 (Bilateral procedure) should not be appended based on this indicator. If the BILT SURG indicator is (1) = Allowed, append the appropriate modifier based on the documentation. Note: Appending a modifier when not allowed could lead to a delay of payment and/or denial. Reference: CMS Medicare Physician Fee Schedule

Error In Appending Modifier FA, F1-F9: These modifiers are to be appended to procedures performed on the fingers only. They are not specific to any other portions of the hand. Units Of Service Error With Modifiers FA, F1-F9: The specific modifiers for the procedures on each individual finger must be coded and reported. It is not acceptable to simply increase the units of service on a single code to indicate multiple digits. Modifier Sequencing: Modifiers FA, F1-F9 are information only modifiers. They are to be sequenced after all payment/pricing modifiers.

Auditors: You will need to put in the specific modifier missed and make a slight adjustment to the error statement based on only one modifier being errantly applied. Reference: Finger Modifier Fact Sheets WPS.GPA / Appendix A of AMA CPT Manual 2018 Modifier 22 Errantly Appended: Modifier 22 was errantly applied to XXXXX procedure code. Per CMS, modifier 22 (Increased Procedural Service) is appended to a CPT code when the documentation supports there was additional effort, complexity and/or time spent in the performance of a surgical service.

CMS provided the following examples of when modifier 22 is applicable: • Dense adhesions are documented as a complicating factor

• Distorted anatomy due to trauma, congenital anomaly or altered due to prior surgery

• Extensive blood loss relative to the procedure performed

• Marked scarring is present and increases the complexity of a service or the time taken to complete the procedure

• Morbid obesity complicates a procedure

• Patient status post-irritation and this creates procedural difficulty

• Presence of excessively large specimen

• Presence of inflammation

• Very low birth weight leads to difficulty performing a service

Review the surgical documentation for indicators on how the surgeon described surgical service differs from a normal, less complex service. Reference: CMS Internet Only Manual (IOM) Publication 100-04 Modifier 22, Appendix A of AMA CPT Manual 2018 Creating this type of standardized audit format will result in establishing consistency in audit feedback and ultimately, enhanced coder performance.


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