Which audit example represents a prospective audit?

Which audit example represents a prospective audit?

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

Answer: (C)

Prospective audits are done before payment to verify that the documentation supports the codes and level of service, preventing improper billing upfront. The audit described—checking whether the provider’s documentation actually supports ICD-10-CM coding—fits this prepayment, forward-looking approach. In contrast, reviews based on carrier denials, issues seen on EOBs, or downcoding on EOBs are retrospective, evaluating claims after submission or after payment to determine if the coding or billing was appropriate.

Prospective audits are done before payment to verify that the documentation supports the codes and level of service, preventing improper billing upfront. The audit described—checking whether the provider’s documentation actually supports ICD-10-CM coding—fits this prepayment, forward-looking approach. In contrast, reviews based on carrier denials, issues seen on EOBs, or downcoding on EOBs are retrospective, evaluating claims after submission or after payment to determine if the coding or billing was appropriate.