The Basics of Auditing Your Pathology Billing, Part 1

November 1, 2004

Whether you perform your own billing, outsource your billing to a firm or have your hospital or group practice perform your billing, there are several key areas that need periodic review to insure that your billing is providing the payment you deserve for services rendered. This series will review billing issues and detail some issues to review when auditing your billing.

The first area to focus on is charge capture, where we have found that significant billing errors are often made. There are several areas of interest here such as charge capture from electronic media, accession tracking, CPT tracking and hold file auditing.

Charge capture from an electronic tape or interface leads to several areas of concern. First, you must run a dual audit system for a period of three months to compare and contrast the actual case verses the tape interface. This will help you find cases that are not making it to the tape or billing file. There are several areas you should review. You should audit this by CPT as it is very easy to lose an entire set of CPT codes off of this type of system. Next, you should audit the file to review revenue center codes from the hospital, because in some situations the revenue center codes are the trigger that puts the charges on the billing file. We have seen situations where none of the billings associated with a particular revenue center were included in the billing file. Another common error occurs when the hospital changes a code in their system and this change is not transferred to the electronic file.

It is imperative that your billing entity review and confirm every accession number. Some firms can actually provide a log of missing accessions to help this process. Every accession number must be provided and accounted for.

Another common charge capture issue that occurs is the situation where a CPT code shows up on the pathology report and also on the electronic file yet never shows up on the biller’s charge master. Again, we have had numerous situations where all parties involved thought all CPTs were captured and billed and yet an audit showed these CPT codes were never actually billed.

The only true way to audit charge capture is to perform an audit that tracks the case from the pathology report to the actual explanation of benefit.

The final area of concern is the demographic pending file. This is a file that your biller builds that holds charge information with no matching demographic information. It is recommended that this file be reviewed periodically to insure complete charge capture.

There are numerous other aspects to correctly auditing your billing and payment situation. We will be reviewing these over the next few months on this site.

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