The best defense against an audit is prevention.
Although, documentation may not be required for initial billing of services, providers should always completely document each patient encounter. While billed services may be completely legitimate, the documentation is the only record of the encounter. If the service is not documented at all or is inadequately documented, the auditor or investigator may deduce that the service was not provided appropriately. Documentation is the only way to substantiate that the care you provided was actually performed.
When billing for the individual services rendered during each patient encounter, it is important to make sure that you are using CPT® codes that most accurately describe these services. Before using a particular code, read the description of that code and make sure it most closely matches the actual services provided. Visit the Coding Resource Center and search by either by CPT® code or keyword.
Conduct a Self-Audit
Providers can best avoid audits and recoupments by performing self-audits. Self-audits are an inexpensive way to double-check that services are properly documented and billed. A self-audit can be performed at any interval. Some practices prefer to self-audit daily before the services are billed, while others prefer to self-audit on a monthly, quarterly, semi-annual, or annual basis. Audits can be performed on every chart for a particular date of service or randomly on a less frequent basis for proper coding, documentation and compliance with provider/insurer contracts.