Perhaps you do not really want to be picked as we are discussing why Medicare or perhaps one of the Blues may pick you to do a preliminary or more in depth audit. There are a variety of reasons you may be audited, but the top 7 reasons that are not due to external issues are detailed below.

  1. Volume – Unfortunately the larger you are, the more likely you are to be audited. This may be based on the number of ablations, total dollars being billed through the Medicare or Blue’s system, or even the number of diagnostic ultrasounds being higher than all other physicians with your primary Board Certification in your state. There’s nothing you can do about this audit trigger save for being very clean on your other potential audit elements and in having very good documentation.
  2. 93970 Overuse – The payers expect to see one full diagnostic ultrasound (93970) per course of treatment. This code is used for a full, hip-to-heel, deep-to-superficial review of the venous system bilaterally. Unless there is a major clinical reason the patient should have another full diagnostic screening, one should suffice. There are codes for other ultrasounds including 93971 which is a limited diagnostic ultrasound (single leg or bilateral) or 76970 – limited ultrasound used after a procedure.
  3. Overuse of Modifier 25 – If you are billing for an office visit the day of the procedure and attempting to be paid by appending the claim with a 25 modifier, you are potentially setting yourself up for an audit. The 25 modifier indicates it is a separate, unrelated office visit. Chances are extremely good that an office visit the same day of the procedure is NOT unrelated.
  4. Segments vs. Entire Vein – This is a two part issue:
    1. We have seen some physicians treat the upper GSV one day and the lower GSV on a separate day. Payers expect to see the entire vein treated during that first encounter.
    2. The number of ablations per patient is frequently the trigger here as one can see upwards of six or more ablations per leg.
  5. Everything is a 5 – If you routinely indicated your new patient exams are a 99205 or your follow up office visits are a 99215, you may be setting yourself up for an audit. Most payers are expecting to see a normal bell curve with the bulk of your visits sitting in the middle 99203/99213.
  6. Documentation – Your documentation is routinely reviewed. You send it in to obtain pre-authorizations. It is sent to appeal a denied claim. A number of agencies are receiving and reading your charts. If the documentation is not sufficiently robust, they may flag you for an audit or further review.
  7. Insurance Medical Director – Asking, frequently, for a peer-to-peer so that you can attempt to change the payer’s policies to meet what you would like to do for your patient (and really annoying the Medical Director) is a very good way to ‘suddenly’ end up in some sort of audit. Not only is the Medical Director annoyed, but you are essentially telling them that you neither like nor want to abide by their policies.

Some of the above are in your control, some are not. The key is to be prepared and to minimize your risk.

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