Audit Triggers for Inpatient

Tags: compliance audit inpatient

High Risk Indicators

Documentation Triggers

Trigger	Risk Level
Cloned notes	High
Missing signatures	High
No daily progress	High
Contradictory info	Medium
Template overuse	Medium

Billing Triggers

Trigger	Risk Level
High level E/M consistently	High
Modifier 25 overuse	High
Critical care daily	High
Multiple initial codes	High
Same day admit/discharge	Medium

Common Audit Scenarios

Critical Care Audits

• Time documentation missing
• Patient not critically ill
• Bundled services billed separately
• <30 minutes billed as critical care

E/M Level Audits

• MDM doesn’t support level
• Time not documented
• Same level every visit
• No progression in complexity

Modifier Audits

Modifier	Common Issue
-25	E/M not separately identifiable
-57	Not decision for major surgery
-AI	Wrong provider using
-59	Overuse without justification

Defense Strategy

Documentation Best Practices

1. Document medical necessity clearly
2. Support MDM with specific details
3. Track time for time-based codes
4. Avoid copy/paste without updates
5. Sign and date all entries

Self-Audit Checklist

• Signatures present
• Dates match DOS
• MDM supports code level
• Time documented (if applicable)
• Modifiers justified
• No cloned content

Quarterly Audits

Perform quarterly self-audits on 5-10 random charts per provider.

Recovery Audit Contractors (RAC)

Focus Area	Lookback
Inpatient Status	3 years
Critical Care	3 years
E/M Levels	3 years
Modifiers	3 years

Appeal Deadlines

Medicare appeals have strict deadlines. Track all audit notifications.

00 Inpatient ProFee Coding MOC Documentation Requirements Inpatient CMS Medicare Guidelines Inpatient