During a pre-submission audit, what information should be validated?

During a pre-submission audit, what information should be validated?

• A. Only the patient name.
• B. Only the CPT/ICD codes.
• C. CPT/ICD codes alignment, modifiers correctness, dates, and NPI information.
• D. Only the payer policy.

Answer: (C)

The main idea here is that a pre-submission audit should verify all the critical data elements that drive claim processing, not just one part of the form. Specifically, you should confirm that the CPT/ICD codes align with the clinical documentation, that any modifiers are correct and appropriately used, that the dates of service match what’s in the chart and the billing period, and that the NPI (provider identifier) information is accurate and matches the payer’s records. This combination ensures the claim accurately reflects what was performed, when it was performed, and by whom, which is essential for proper adjudication and to minimize denials. Focusing on only one item, like patient name or payer policy, misses other high-impact areas that often cause rejections—coding accuracy, the presence and meaning of modifiers, date discrepancies, and correct provider identification. The payer policy is important, but it doesn’t replace the need to validate the actual data elements that determine how the claim will be evaluated and paid.

The main idea here is that a pre-submission audit should verify all the critical data elements that drive claim processing, not just one part of the form. Specifically, you should confirm that the CPT/ICD codes align with the clinical documentation, that any modifiers are correct and appropriately used, that the dates of service match what’s in the chart and the billing period, and that the NPI (provider identifier) information is accurate and matches the payer’s records. This combination ensures the claim accurately reflects what was performed, when it was performed, and by whom, which is essential for proper adjudication and to minimize denials.

Focusing on only one item, like patient name or payer policy, misses other high-impact areas that often cause rejections—coding accuracy, the presence and meaning of modifiers, date discrepancies, and correct provider identification. The payer policy is important, but it doesn’t replace the need to validate the actual data elements that determine how the claim will be evaluated and paid.