10 Methods To Avoid Audits

Accurate claims and complete records can reduce avoidable denials and make Medicare reviews easier to manage. These ten checks support your billing workflow, but no checklist can guarantee that a practice will avoid an audit.

1. Confirm Accurate Data Entry:

   • Ensure that all data pertaining to the service is accurate. Even a minor mistake, such as an incorrect date of service, can cause a claim to be denied. Take a few seconds to scan your claim for accuracy before submitting it. This simple step can save a significant amount of time and effort later.

2. Understand Local Coverage Determinations (LCDs):

   • Familiarize yourself with LCDs, which outline whether a specific service is covered on a local level. LCDs vary by jurisdiction, so always check your local MAC’s (Medicare Administrative Contractor) guidelines. Resources such as the CMS LCD Database provide valuable information.

3. Familiarize Yourself with National Coverage Determinations (NCDs):

   • NCDs describe national Medicare coverage policies. Check the policy that applies to the service and date of care in the CMS coverage database, along with applicable billing guidance.

4. Use Modifiers Appropriately:

   • Choose modifiers based on the service performed, the code definition and the supporting documentation. Do not add a modifier simply to bypass a denial. The AAPC Modifier Guide provides an introduction; confirm the applicable Medicare and payer rules before billing.

5. Document Repeat or Duplicate Services Thoroughly:

   • If you provide a repeat or duplicate service, ensure your documentation shows the distinct nature of each service. Use appropriate modifiers such as 76 (Repeat procedure or service by same physician) and document each instance separately to avoid denials.

6. Submit Supporting Documentation When Necessary:

   • When using modifiers that require additional detail, such as modifier 52 (Reduced services), submit the necessary supporting documentation. LCDs or NCDs may specify the requirement for additional records. Failing to do so can result in denials.

7. Respond Promptly to Documentation Requests:

   • If your MAC requests additional documentation, respond immediately. Delays in providing the requested information can slow down reimbursement. Make sure all required documents are sent promptly to avoid unnecessary delays.

8. Check Signature Requirements:

   • Confirm that records meet the applicable authentication requirements. Review the CMS signature requirements for acceptable signatures, exceptions and the circumstances in which a signature log or attestation may be used.

9. Describe Unlisted Procedure Codes:

   • When using unlisted CPT® codes, describe the service clearly and follow your contractor’s instructions for the claim narrative and supporting records. Confirm the required submission method before sending additional documentation or another claim.

10. Ensure Providers Are Properly Credentialed:

    • Verify the Medicare enrollment and billing requirements that apply to the ordering, referring, rendering and billing practitioners. Do not assume one practitioner can bill under another’s identifier. Arrangements such as incident-to services have specific requirements that must be met.

For appeal procedures and next steps, consult the CMS Original Medicare appeals guide and the instructions from your Medicare Administrative Contractor.

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Additional Resources:

• CMS LCD Database
• CMS NCD Database
• AAPC Modifier Guide
• Learn Medicare Billing – Site Visit Checklist
• CMS Original Medicare Appeals Guide
• Centers for Medicare & Medicaid Services (CMS)

Updated: 5/24/2024