Audit, Scope, and Statistical Sampling Methodologies

Question 1

What is RAT-STATS?

Answer 1

A statistical sampling software offered by the OIG to assist in claims review.

Question 2

As an auditor, you work for a CPA firm who has been asked to perform an audit of a new practice to determine risk areas for their documentation. There have not been any prior audits at this practice. What type of audit should be performed?

Answer 2

Random audit

Question 3

What is non-statistical sampling?

Answer 3

Sample based on unique services that were defined in the objective and scope and is used in focused audits.

Question 4

How often should an internal audit be conducted minimally?

Answer 4

Annually

Rationale: At a minimum, the internal audit should be conducted annually (and more often if problem areas have been identified).

Question 5

What is an example of support documentation that is found in the NCCI manual?

a. E/M documentation guidelines
b. Correct use of modifiers, including modifier 25
c. Correct use of anesthesia modifiers
d. Diagnostic guidelines

Answer 5

b. Correct use of modifiers, including modifier 25

Question 6

What type of error might be found by reviewing the encounter form and claim form?

a. The level of service is not supported by the documentation.
b. Bundling edits are not being followed.
c. Medical necessity is not supported for the services.
d. Keying errors occurring during the data entry process.

Answer 6

d. Keying errors occurring during the data entry process.

Question 7

Which type of audit often realizes more objectivity than with an employed auditor?

Answer 7

External audit

Question 8

As an auditor, you have completed an audit of a practice and noticed that one provider consistently had history and exam levels above the levels of medical decision making, causing a higher level of E/M service to be reported. His utilization pattern compared to the rest of the practice shows higher level of E/M services reported overall. Concerned that the provider is not supporting the medical necessity of the visits in the documentation, what type of audit should you suggest for the practice?

Answer 8

Peer review

Rationale: A peer review audit may be performed if the clinical decision-making is being questioned, based on the documented exam and treatment plan. Some practices use a peer review audit on a quarterly basis to provide feedback among the providers. As a provider is performing a peer review audit, he or she can take into account the coding accuracy, as well as the clinical information, if the clinician is comfortable in that area.

Question 9

When defining the scope of an audit, which question would NOT apply?

a. Will the audit be limited to only government payers?
b. Will the audit results be shared?
c. Are all providers to be included in the audit?
d. Will the audit be limited to E/M codes only?

Answer 9

b. Will the audit results be shared?

Question 10

What is an example of how office policies are helpful in an audit?

a. Office policies outline termination procedures for employees.
b. Office policies provide specification on OSHA policies.
c. Office policies determine the medical necessity of services performed.
d. Office policies may specify what to bill when a preventive service and problem visit are provided at the same time.

Answer 10

d. Office policies may specify what to bill when a preventive service and problem visit are provided at the same time.

Response Feedback:
Rationale: When auditing preventive medicine services or annual

Question 11

An audit performed prior to claims submission is referred to as what type of audit?

Answer 11

Prospective audit

Rationale: A prospective audit is performed prior to claim submission. This type of audit allows variances in the coding to be corrected prior to claim submission.

Question 12

Which resource is valuable when performing an evaluation and management audit for office visits?

a. Surgical Audit Tool

b. NCCI Manual

c. AMA CPT® Evaluation and Management Documentation Guidelines

d. Advance Beneficiary Notice (ABN)

Answer 12

c. AMA CPT® Evaluation and Management Documentation Guidelines

Question 13

What tool might be helpful in defining which services to audit for a focused review?

Answer 13

Utilization reports

Rationale: Utilization review and data mining provide insight into billing patterns and can help uncover areas of risk. Utilization review is a technique that provides data about how frequently certain services are billed. A utilization pattern can be found from looking at the utilization review to evaluate coding patterns.

Question 14

An audit performed after the claims have been submitted is referred to as what type of audit?

Answer 14

Retrospective audit

Question 15

What is a utilization review?

Answer 15

A technique that provides data about how frequently certain services are billed.

Question 16

Which list represents the most comprehensive list of items reviewed in a retrospective audit?

a. Encounter form, system reports for charge entry, claim form, explanation of benefits or remittance advice, and payer policies

b. Medical record documentation, encounter form, claim form, explanation of benefits or remittance advice, and payer policies

c. Medical record documentation, encounter form, system reports for charge entry, claim form

d. Medical record documentation, explanation of benefits or remittance

Answer 16

b. Medical record documentation, encounter form, claim form, explanation of benefits or remittance advice, and payer policies

Rationale: To perform a retrospective audit, an auditor reviews the medical record documentation, encounter form, claim form, and the explanation of benefits (EOB) or Remittance Advice (RA), and the payer policies to determine if there are errors in the process and identify where the error occurred.

Question 17

What is considered good parameters for a baseline audit?

Answer 17

Random audit of 10-15 records per practitioner.

Rationale: A baseline audit should be 10-15 records per practitioner and include a sampling of various levels of E/M services, along with office and surgical procedures selected randomly.

Question 18

A practice manager runs reports on services billed to Medicare. The reports identify a large number of surgical services reported with modifier 22. As a result, you are hired as an external auditor to review the services identified in the report. What type of audit would you perform?

Answer 18

A focused audit on surgical services with modifier 22.

Rationale: Because an outlier of surgical services reported with modifier 22 has been identified, and this is the reason for the retention of an external auditor, a focused audit of surgical services reported with modifier 22 would be performed.

Question 19

From an audit perspective, consulting the MAC website for guidance regarding medical necessity coverage decision can be an opportunity to see if what form is being used and completed correctly?

Answer 19

Advanced beneficiary notice (ABN)

Question 20

What is/are the advantage(s) of a peer review audit?

A. Clinical decision-making can be addressed.
B. Coding accuracy.
C. Provides feedback among providers.
D. All of the above.

Answer 20

D. All of the above.

Question 21

A practice contacts an external auditor and explains the practice is billing incident-to services and is not sure they are documenting appropriately, or following the guidelines. What services would the external audit focus on during an audit based on this information?

Answer 21

NPP services provided in the practice.

Rationale: Incident-to refers to services provided by NPPs but reported under the supervising physician’s provider number.

Question 22

What is proportional sampling?

Answer 22

Sampling based on high frequency items, or those items that are considered to be proportionally significant.

Question 23

What would be more readily available to an internal auditor versus an external auditor?

a. Commercial carrier contracts
b. MAC policies
c. Authorized medical record documentation
d. CMS policies

Answer 23

a. Commercial carrier contracts