When a code change is the result of the audit, what should the auditor identify?

When a code change is the result of the audit, what should the auditor identify?

• A. The appropriate fee schedule allowance in effect at the time and the financial impact.
• B. The current patient roster.
• C. The provider's personal beliefs.
• D. The total number of claims processed.

Answer: (A)

When a code change comes from an audit, the crucial point is to tie the change to the payment rules that were in effect when the service occurred and to understand the financial effect of that change. Fee schedules determine how much a payer will reimburse for a given code, and they can vary by payer and time. By identifying the appropriate fee schedule allowance in effect at the time of service and calculating the financial impact, the auditor can determine what was paid, what should have been paid, and what adjustments are needed. This supports accurate recoupment or refunds and maintains billing compliance with payer policies. The other items—the current patient roster, the provider’s personal beliefs, or the total number of claims processed—don’t directly establish the correct reimbursement or the necessary adjustment for a specific code change.

When a code change comes from an audit, the crucial point is to tie the change to the payment rules that were in effect when the service occurred and to understand the financial effect of that change. Fee schedules determine how much a payer will reimburse for a given code, and they can vary by payer and time. By identifying the appropriate fee schedule allowance in effect at the time of service and calculating the financial impact, the auditor can determine what was paid, what should have been paid, and what adjustments are needed. This supports accurate recoupment or refunds and maintains billing compliance with payer policies.

The other items—the current patient roster, the provider’s personal beliefs, or the total number of claims processed—don’t directly establish the correct reimbursement or the necessary adjustment for a specific code change.