By Meg DeVoe, CCS; Lori Amende, RHIA, CCS; and Karen Scott, MEd, RHIA, CCS-P, CPC, FAHIMA
In today’s healthcare environment, organizations face many challenges, including periodic coding audits originating from various outside entities that focus on many different coding issues. Given that these audits can tie up valuable resources, a solid strategy is needed to minimize and defend against them. Here are several smart steps that your healthcare organization can take to prepare for audit success.
Proactive Internal Compliance Is Key to Reducing External Audits
Establishing an internal compliance program can help you identify and address coding accuracy issues before they trigger an audit. This can be achieved by:
- Conducting baseline internal audits that include: A random audit of 10-25 records per coder/physician that can identify patterns and help to determine where additional focused reviews of a specific diagnostic-related group (DRG), ambulatory payment classification (APC), diagnoses, or procedures may be needed
- Independent audits performed by external coding auditors that include: A random audit performed at least once per year that can help identify areas where additional coding education would be beneficial for specific coders or the whole coding team
These audits can help you recognize important patterns such as:
- Coders who do not consistently meet quality standards
- Specific diagnoses or procedures that are frequently coded incorrectly
- Areas that need further review, such as documentation deficiencies or medical necessity issues
A dynamic and consistent internal compliance program is the best way for your organization to identify and correct coding issues quickly and reduce the impact of external coding audits.
You’ve Been Notified of an Outside Audit. Now What?
Even with a solid compliance program in place, recovery audit contractor (RAC) or payer audits still occur that can result in diagnosis related group (DRG) or ambulatory payment classification (APC) changes, which in turn can impact reimbursement for your organization. The good news is that you have the right to appeal the decision.
Get to Know the Appeals Process
Keep up to date with the audit organization’s policies and procedures regarding appeals. Track audits as they are received to ensure that appeal deadlines are met.
Have a Physician Champion in Your Corner
As part of their clinical documentation integrity (CDI) programs, many hospitals are designating a physician champion whose role includes defending against audits through documentation and appeals letter support.
Look for Trends that can Help Prevent Future Denials
Tracking denials by DRG/APC, physician, and frequency can help you to proactively identify cases that are at risk for a denial.
Utilize Coding Tools that Help Support a Successful Compliance Program
Whether you’re conducting internal audits or defending against external ones, having the right coding resources conveniently at your disposal is a significant advantage. With the TruCode Encoder, you have instant access to:
- All present and past coding guidelines
- Official coding references
- Customizable coding instruction for your staff
- Edits to help identify potential coding errors
The knowledge-based TruCode Encoder’s intuitive design and streamlined workflow not only enables more efficient and accurate coding from the start, it also provides all the resources you need to help defend against any audit that may come your way. To schedule a demo of the TruCode Encoder, please visit www.trucode.com/demo.
Register for AHIMA20
The AHIMA20 Virtual Conference is the premier educational, exhibition, and networking event for health information professionals. Whether you are seeking cutting-edge education, evaluating the latest market innovations, or are seeking new professional connections, the AHIMA20 Virtual Conference is the place to be. Register today.
Meg DeVoe, CCS is Product Manager, Lori Amende, RHIA, CCS, is Product Specialist, and Karen Scott, MEd, RHIA, CCS-P, CPC, FAHIMA, is Director of Education and Training at TruCode, an innovator in the medical coding software market. TruCode provides an encoder application, components and web services to the hospital, consulting and healthcare IT marketplace. Its software is used by more than 1,800 professionals in more than 600 healthcare organizations.
Hear from past attendees why they attend the AHIMA conference every year.