Which audit example represents a prospective audit?

Which audit example represents a prospective audit?

• A. An audit to evaluate if a provider's documentation supports ICD-10-CM coding.
• B. A focused audit based on denials from an insurance carrier.
• C. An audit based on bundling issues identified on EOBs.
• D. An audit based on a payer downcoding E/M levels on EOBs.

Answer: (A)

The main idea is timing: a prospective audit happens before a claim is submitted, aiming to prevent errors by verifying that the available documentation supports the codes that will be billed. Checking whether a provider’s documentation supports ICD-10-CM coding fits this, because it ensures the right codes are supported and accurate before billing goes out. The other scenarios involve looking at what happened after submission—denials from a carrier, issues seen on explanation of benefits, or downcoding found on EOBs—so they’re retrospective, analyzing past claims rather than preventing issues upfront.

The main idea is timing: a prospective audit happens before a claim is submitted, aiming to prevent errors by verifying that the available documentation supports the codes that will be billed. Checking whether a provider’s documentation supports ICD-10-CM coding fits this, because it ensures the right codes are supported and accurate before billing goes out.

The other scenarios involve looking at what happened after submission—denials from a carrier, issues seen on explanation of benefits, or downcoding found on EOBs—so they’re retrospective, analyzing past claims rather than preventing issues upfront.