Three Must-Do Compliance Tasks for Smaller Practices

Betsy Nicoletti, M.S., CPC August 13th, 2012

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Many large groups have a dedicated compliance officer and even (gasp) compliance auditors and support staff whose only responsibility is compliance.  For smaller groups, compliance duties are shared by the manager, physician leader, and billing and coding staff, all of whom have multiple other responsibilities.  How to find time?  And if you are able to steal time from another task, where do you start?

Here are three important activities that won’t take all day, but will protect your practice.

1. Do a non E/M coding review

Print out a list of billed CPT codes by volume and revenue, and ignore E/M services.  Make a list of your top five codes billed by volume and revenue.  In all likelihood, some codes will be on both lists, so you will end up with a list of five to ten of your most frequently billed non-E/M services.

Next, review the CPT definition for the codes, read the editorial comments in the CPT book related to the services.  If you have any other up-to-date coding resources about the codes or coding instructions from Medicare on one of your payers (a National or Local Coverage Determination, for example) print that out and review it as well.

Next, pull five records billed with each of your most frequent codes.  Review the documentation.  Does the documentation describe the procedure as defined by CPT?  Does the note support the medical necessity or indication for the service? If the service is diagnostic, is the reason for the test documented in the record?  Document your findings on a spreadsheet.  Refund incorrectly paid amounts and educate your staff and providers.

2.  Check NPI billed numbers

CMS is serious about enrollment and accurate claim submission with the correct NPI. Locums, shared services, and incident to service have specific rules.   For this compliance review, trace the NPI on the claim submitted with the name in the medical record documentation.  Do they match?  Is the correct NPI being submitted in both the electronic and paper formats?  If there is a discrepancy, was it because of a shared service, incident to or locums billing?  Record your findings on a spreadsheet.  Errors in this are serious and most consultants would recommend talking to your practice attorney about discrepancies. 

3.  Avoid the wall of shame

This activity will probably take more than a day, and may require outside help.  A practice that loses 500 or more records is required to self-disclose their protected health information breach on the wall of shame.  Google HHS Wall of Shame and see for yourself.  Some of the most common breaches occur because of loss or theft of a computer that contains protected health information.  Simple solutions:

  • Encrypt data
  • Set up laptops to access medical records but not download them
  • Require frequent password changes, and no passwords on sticky notes
  • Use physical security to secure computer servers to the wall
  • Hire a security expert to do an assessment

Review your security policies frequently at staff meetings and with new staff.  Make sure no one is using a non-secured email to send or receive patient records.

Finally, schedule yourself an hour a week to just read about coding and compliance issues in physician practices.  Turn off the phone and email, and find a hideout.  Go to the library or a coffee shop.  All week long, save the articles, emails and resources that appear in your electronic and paper inbox.  During this learning hour, catch up and give yourself time to process all of the information coming your way.  If an ounce of prevention is worth a pound of cure, an hour of learning will save weeks of pain.

Betsy Nicoletti, M.S., CPC, is the founder of, a wiki for physician reimbursement. She is a nationally known speaker and consultant, and can be reached at She most recently wrote for Getting Paid on Your Nine-Step Plan to Better Practice Collections, Part I and Part II

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