Simply mentioning a coding audit sends a shiver up a coder’s spine. The thought of scrutinizing their coding quality, as they strive to balance quality and productivity, can bring dread to even the most seasoned coder.
But conducting internal or external coding audits are an important part of ensuring quality and regulatory compliance for hospitals and health systems. Knowing these 8 facts about audits can help you and your team prepare for your next audit, alleviate stress, and make sure you are getting the most out of it.
- Audits are a regular occurrence – Coding is a critical part of how payers determine claims, so it’s an area that invites routine audits. These are administered internally, by regulatory organizations, such as Center for Medicare and Medicaid Services, Office of the Inspector General, and by payers. Audits are a part of the business.
- What’s the goal? – Generally, each audit has a primary focus and you need to make sure you understand it. Is the focus a new documentation issue? A reoccurring compliance issue? Or a coding hot topic trend? Why are there frequent denials for a certain DRG? Why does one physician have a higher percentage of Level 5 Evaluation and Management codes?
- Preparation – Gather all necessary information regarding the audit focus, related coding and documentation rules, internal coding polices, and documentation requirements. Keeping current with industry coding issues is a great way to anticipate audit trends and it is best to discuss these topics regularly during internal coding team meetings.
- Be a coder, not an auditor - Avoid overthinking the process to the point of crippling coding decisions by becoming both coder and auditor for every account coded. Promote confidence within your team for their coding decisions.
- Stick to the rules – Be sure all coding decisions are based on official coding guidelines, as well as reimbursement rules and regulations, and supported by source medical record documentation.
- There will be auditor recommendations – Keep an open mind and accept the fact there will be auditor recommendations. Acknowledge any oversights that did occur and that something may be missed during the initial coding process. In the end, feedback is a gift and the recommendations will make your team better coders.
- Rebuttal Time! – There will always be different opinions and interpretations of coding. Review auditor recommendations with an open mind, but if there is a disagreement with the auditor’s recommendation, a formal rebuttal process should be activated. Give the coder the opportunity to present their initial coding justification, including references to supporting their coding, i.e., AHA Coding Clinic, official coding guidelines, documentation support from the medical record, etc.
- It’s about improving – Remember, an audit presents a learning opportunity. Especially with internal reviews, the goal is to find deficiencies or gaps in your coding so you can assess where there is a need for education and training. An audit can start a discussion around identified concerns and can provide a forum for resolving coding and documentation issues. If your goal is continual improvement, audits are a great way to identify what to focus on.
Coding audits can be stressful. But partnering with a third-party like MRA can make sure you are ready and confident heading into your next regulator or payer audit. We do assessments, conduct internal reviews and then provide personalized training and education based on our findings.
If you are ready to continue the conversation, contact MRA today.
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