Worries and Warnings: What Really Triggers a Payer Audit?

“I've heard that I might get audited if I bill too many level 4 visits.”  “I told her that if she kept using that modifier so much she'd get audited!” How many times have you heard a statement like this? Either a clinician is worried about a payer audit, or a coder or consultant is warning about an audit. Both worries and warnings can cause clinicians to under code, hoping to “fly under the radar.”

What really increases the risk of an audit from Medicare or government payer? 

Every coder and clinician can cite some obvious risks. Using high level codes at a higher frequency than the norm for the specialty or using modifiers 25 or 59—one of the modifiers that bypasses the claims editing system—at a particularly high rate. These are the most obvious topics for worries and warnings. The problem, however, is that the government and private payers have claims data for all physicians who participate with them and can sort it by specialty. That is, third parties know how frequently an orthopedist uses modifier 25, but how does an orthopedic practice know this? What is the frequency of high level visits reported by cardiology? The payers have a full deck of cards and we have only the ace of spades and the two of clubs. Some data is available for purchase by commercial vendors, but not all practices have access to it. In the absence of that data, here are some things that you can do:

• In a large group practice, compare physicians of the same specialty for frequency of high-level visits and use of modifiers. Check with your specialty society for any normative data that they have available for members on E/M frequency or the use of modifiers.
• The OIG identified clinicians who were reporting the two highest levels of service in every category more than 95% of the time. Look at your clinicians and compare the percentage that each reports of the two highest levels codes in each category.
• Many groups have access to MGMA work relative value unit (RVU) data. A clinician with very high volume compared to the MGMA median may be the target of an audit.
• Pay attention if you receive a letter from a third party payer that a clinician uses a high level code or a modifier more frequently than the norm. This is an indication for an internal audit.

  ​Some types of service are also higher risk than others. How do you find out what those services are? There are three sources of publicly available information. Review the annual OIG Work Plan. It lists areas that the government considers to be areas of interest. Look at the RAC list of issues for your region. These can be sorted by type of provider, making it easy to see what physician services are RAC targets. Review the Medicare CERT reports which identify types of service and, sometimes, specific CPT codes that have a high error rate. Providing services that are on one of these lists, especially at a high volume, does increase your risk of audit. Decrease worries by identifying these services, reviewing the coding rules related to each one and doing an internal audit. Consider these three sources—the OIG Work Plan, RAC issues and CERT reports—as warnings that will allow you to decrease your worries.