No One-Size-Fits-All Answer for Frequency of Billing and Coding Audits

Q. How often should a laboratory conduct compliance audits of its billing and coding?

A. The answer depends on many factors and will vary from provider to provider.

The Office of Inspector General’s Compliance Program Guidance for Clinical Laboratories includes among its seven elements for a comprehensive compliance program “use of audits and/or other evaluation techniques to monitor compliance and assist in the reduction of identified problem areas.”  It further explains that an “ongoing evaluation process” that involves “regular” audits is “critical to a successful compliance program.” The guidance also indicates labs should at least annually review whether its compliance program is implementing the OIG’s seven elements. But it doesn’t specify the frequency of audits specifically for billing and coding.

The frequency of audits and reviews of billing and coding is a function of risk, size of the laboratory and complexity of its service offering, complexity of its client portfolio, how often critical changes occur in the laboratory’s billing and coding procedures, and the resources available to the compliance officer to conduct the audits and analyze the data. Audits of all facets of a laboratory claim submittal and the associated policies and procedures should be done at least annually. If the laboratory is very large, the audits may have to be split up and performed piecemeal over the course of a year in order to make sure every area is audited at least annually. High-risk or problematic areas may need more frequent audits to ensure accurate claims submittals are occurring.

A version of this article appeared in the March 2014 issue of G2 Compliance Advisor. If you have similar compliance questions you would like to see us address in G2 Compliance Advisor, please forward them to Kelly Hardy Briganti, Editorial Director, G2 Intelligence at kelly@g2intelligence.com.