A smart mix of audit types to maintain coding quality

Feb. 27, 2019 / By Kristine Daynes

Compliance requires exacting skills. HIM departments are expected to make sure patient care is appropriately documented, check for medical necessity, assign codes with ICD-10 specificity, identify conditions present on admission (POA), flag patient safety indicators (PSIs) and hospital-acquired conditions (HACs), and more.

Market and technology trends add to the strain. Coding and CDI managers may also be supporting diagnosis coding for HCC risk-adjustment, clinical validation of chronic conditions, and fluency with both facility and professional coding, for example. These new skills require precision and efficiency.

Claims that fail to meet scrutiny can be rejected by payers fully or in part. To ensure claims are compliant before submission, most health systems follow a coding compliance program to ascertain whether or not coded records conform to guidelines, reducing the likelihood of denials and delays.

The optimal compliance program includes a mix of coding audit types, according to my colleague, Sue Belley, who has spent her career managing coding, CDI, and audit programs. She describes how a balanced approach can address both payer compliance and operational improvements that benefit efficiency and revenue.

According to Sue, some facilities feel they don’t have time for prebill audits, assuming it is better to retrospectively audit and rebill claims. However, this can attract the attention of external auditors. It may be wiser to review critical cases daily, especially for high-risk patients, so that those claims are submitted accurately and do not misrepresent patient outcomes or get delayed by the payer.

Monthly retrospective audits allow managers to monitor coding performance and uncover opportunities to rebill. They can alert you when staff need education to maintain quality.  

Other types of audits meet specific needs. Ad hoc audits are useful when your organization detects problematic trends, such as a shift in reimbursement for a service line or DRG. An audit can uncover the cause and help managers remedy any incomplete documentation or inaccurate coding. Similarly, a focused coding quality audit targets a specific area, such as a PSI, or a high-risk area, such as malnutrition, to verify documentation and coding.

Random audits can surface issues that might otherwise go undetected. For example, many coders have mastered ICD-10 specificity for conditions directly represented by readmissions and complications. But they are only beginning to investigate contributing factors, such as under-dosing of medication. Although it might not be explicit in the documentation, under-dosing can be clearly evident when a patient takes less or receives less than the prescribed dose. This is relevant in coding the record for a patient  with congestive heart failure that does not take his prescribed diuretic and is readmitted to the hospital with acute heart failure.

An external audit provides fresh eyes to check blind spots. Because an external auditor is unaffiliated with the organization, it also provides an unbiased report card, similar to a financial report certified by a CPA. It can validate for a coding manager that the team is meeting standards or pre-emptively identify problem areas before a regulatory audit is triggered.

Sue is quick to point out that coding audits do more than protect organizations against denied payment and non-compliance penalties. For health systems that maintain a research database, audits help ensure that patient conditions, treatments, and medications are accurately represented. Coding accuracy helps avoid patient complaints stemming from misrepresented conditions (e.g., HPV miscoded as HIV) and rejected insurance claims (e.g., wrong condition does not meet medical necessity). Coding accuracy supports better tracking of infectious diseases and quality measures, too.

Kristine Daynes is a senior product manager at 3M Health Information Systems.