Medical Auditing Practice Exam

When reviewing denials for incorrect coding, what is the first step an auditor should take?

1. Contact the payer

2. Review the coding guidelines

3. Analyze the claims history

4. Prepare an appeal letter

The correct answer is: Review the coding guidelines

The first step an auditor should take when reviewing denials for incorrect coding is to review the coding guidelines. This is essential because coding guidelines provide the framework and rules for accurate coding practices, ensuring that codes used are in compliance with payer policies and regulations. By reviewing these guidelines, the auditor can identify any discrepancies or errors in the coding that led to the denial. Understanding the specific coding rules associated with the services provided allows the auditor to assess whether the codes applied align with the requirements set by professional coding resources, such as the ICD-10, CPT, and HCPCS code books. Familiarity with coding guidelines also supports the auditor in determining if the denials are justified or if there is a valid reason for an appeal based on a coding mistake. In contrast, contacting the payer, analyzing claims history, and preparing an appeal letter are subsequent steps that involve additional actions once the coding guidelines have been reviewed and applied to the case at hand. Therefore, beginning with a thorough review of the coding guidelines establishes a solid foundation for addressing the denial effectively.