Best Practices For Internal Audits In Cardiology Billing Compliance


By Isaac Smith, Billing/coding/reimbursement/compliance specialist, Medcare MSO

Isaac is a highly accomplished healthcare professional with over 13 years of experience in healthcare administration, medical billing and coding, and compliance. He holds several AAPC specialty certifications and has a bachelor’s degree in Health Administration. He worked previously at a large multi-physician family care and occupational health practice with two locations in northwestern PA and now works for Medcare MSO in the ICD-10 Editorial department to write articles about medical billing coding and compliance. He enjoys sharing his knowledge and experience as a certified PMCC instructor.

Clinical documentation, coding, and billing practices in a medical organization must be evaluated through internal audits. Due to increased payer scrutiny and regulatory requirements, internal audits can help ensure that revenue cycle processes are compliant and operating efficiently to prevent inefficiencies or malpractice. An internal auditor or a medical billing and coding company that specializes in the field may conduct an audit of documentation and financial performance.

Cardiology billing compliance and documentation are essential for accurate cardiology billing and reimbursement, regulatory compliance, and avoiding penalties. This blog post will discuss cardiology practice billing compliance and documentation best practices.

Purpose of Internal Audits

Medical records are audited for coding accuracy, policies, and procedures. A billing audit covers the entire medical billing cycle, including eligibility verification, demographic data capture, medical coding, claims submission, payment posting, accounts receivable, and denial management. Medical billing audits identify areas for improvement.

Internal Medical billing audits can uncover many issues:

  • Provider documentation errors
  • Incorrect codes, deletions, and frequency
  • Overcoding, undercoding, unbundling, and modifier use
  • Reimbursement issues
  • Payer non-compliance
  • Unintentional billing fraud
  • Medical practice claim scrubber software errors

Your practice can avoid Medicare penalties by having a medical billing audit. It also identifies and addresses RAC-sensitive risk areas.

Best Practices for Establishing Internal Coding Audits

  1. Establish your coding compliance goal

Facilities should standardize coding quality measurement. A coding audit will identify root causes of coding errors, reducing variance and increasing reliability. Second, an audit will identify coder strengths and weaknesses, helping set education goals.

  1. Appoint a qualified internal auditor

Depending on your ASC’s organizational structure, qualified and credentialed coding managers/supervisors, lead coders, or compliance departments can review. The internal auditor should be certified in ASC coding policies and guidelines. Since medical credentials (RN, LPN, MD) do not guarantee coding auditor qualifications, it is best to be cautious. If your facility doesn’t have an internal auditor, hire an ASC auditing consultant or company. until coding accuracy percentages are acceptable and consistent.

  1. Determine the frequency of reviews

Internal audits—how often? Monthly? Quarterly? Annually? Bi-annually? Variables determine frequency. Case volume may require more audits. A random internal audit may suggest more frequent and focused auditing of problem specialties. Quarterly internal audits with an annual external audit to verify consistency are best.

  1. Determine the financial classes

Many ASCs prioritize RAC audits and Medicare reimbursements, but commercial payers make coding errors. Your initial baseline audit should include Medicare and commercial financial classes. If variances show a trend, a payer or specialty-specific audit may be needed.

Understand Comply with Coding and Documentation Guidelines:

Cardiology practices must follow CMS and AMA coding and documentation guidelines for proper billing and documentation. Learn CPT, ICD, and other coding systems.

Ensure Accurate and Specific Diagnosis Coding:

Correct diagnosis coding ensures accurate reimbursement and clinical picture. Cardiologists should use accurate ICD codes. Avoid generalized codes. Review and update your diagnosis coding practices as coding guidelines change.

Establish Clear and Comprehensive Documentation Standards:

Medical necessity and service billing require thorough documentation. Cardiology practices should standardize documentation templates and guidelines to ensure provider consistency. Document patient history, examination, test results, treatment plans, and follow-up care.

Use Appropriate Time-Based Documentation:

Time-based E/M and prolonged services in cardiology require specific documentation based on patient care time. Document such services’ start and end times and activities.

Maintain Compliance with Incident-to Billing Rules:

Incident-to-billing rules are crucial for cardiology practices with NPPs. These rules require NPPs to bill under the supervising physician’s NPI. Make sure NPPs meet requirements and the supervising physician is involved in patient care.

Compliance Gaps In Cardiology Billing Processes

Healthcare organizations may fail to follow regulatory requirements, coding guidelines, or cardiology billing policies. Cardiology billing compliance gaps include:

Documentation Insufficiency:

Poor cardiology documentation can lead to billing errors and non-compliance. Medical necessity, procedure complexity, and patient severity may be lacking in inadequate documentation. Incorrect code assignment and compliance issues may result.

Improper Code Selection:

Cardiology billing compliance gaps include incorrect diagnosis or procedure codes. Cardiology procedures and conditions are complex, requiring accurate code assignment for reimbursement. Incorrect code selection can cause underpayment or overpayment, posing compliance and financial risks.

Inconsistent Application of Coding Guidelines:

Compliance gaps can occur when AMA, CMS, or payer-specific coding guidelines are not followed. Coding errors, claim denials, and compliance issues can result from coding deviations.

Lack of Up-to-Date Knowledge:

Compliance gaps can occur when coding and billing staff are not properly trained or aware of the latest coding guidelines and regulations. Cardiology billing compliance requires ongoing training due to healthcare regulations’ fluidity.

Insufficient Internal Auditing and Monitoring:

Failure to conduct regular internal audits and monitoring of cardiology billing processes can contribute to compliance gaps. Without ongoing evaluations, organizations may overlook potential issues, coding errors, or billing discrepancies that could lead to compliance violations.

Non-Compliance with Applicable Regulations and Guidelines:

Failure to comply with HIPAA, the FCA, or payer requirements can cause cardiology billing compliance gaps. To reduce risks, organizations must monitor regulatory changes and comply.

Healthcare organizations should improve documentation, staff training, internal audits, and cardiology billing processes to close compliance gaps. Organizations can minimize compliance gaps, ensure accurate billing, and reduce audits, penalties, and reputational damage by implementing effective compliance programs and following coding guidelines and regulatory requirements.