Checklist: Prep for a Successful Coding Audit

By Angela Knight, CHCAF, CHTSIM, RHIT, Director, Audit | Posted: 10/27/2020

Hospital coding preparation

Accurate and efficient medical coding is crucial to a health care provider’s ability to optimize reimbursement and meet compliance requirements. All hospitals and health care organizations should maintain a robust coding quality compliance plan with periodic coding audits while providing education opportunities to staff members that will strengthen coding processes. These coding audits are vital to assessing health care data quality, coding compliance & documentation, and identifying areas of risk while providing actionable recommendations for improvement.

There are many components to consider to better prepare your health care organization and ensure that a successful medical coding audit will take place. A lack of proper planning can result in reimbursement discrepancies, increased compliance risks and less than optimal financial performance within your revenue cycle.

  1. Determine the frequency of medical coding audits

    Identify the frequency for coding audits: daily pre-bill, monthly, quarterly, semi-annual, or annual. Alternating random and targeted chart selection for each quarterly review allows hospitals and health care providers to compare auditing results from year to year within each quarter and achieve a well-rounded coding compliance program.

  2. Consider the scope

    Will the scope of your health care organization’s upcoming coding audit include inpatient, outpatient, professional fee, or a combination?

    Inpatient

    • Total data quality (validation of all codes) or DRG validation only?
    • MS-DRG and/or APR-DRG?

    Outpatient

    • Which outpatient service types are to be included? Emergency department, same day surgery, endoscopy, observation, wound care, ancillary/diagnostics, recurring such as physical therapy, occupational therapy, chemotherapy, blood transfusions, interventional radiology, clinics, etc.
    • Will the review include only HIM coding or also Charge Description Master (CDM)-assigned CPT codes?
    • Will the review include validation of injection and infusion services?
    • Will the review include validation of facility-reported E/M levels?
    • Will medical necessity for tests performed and services rendered against Local Coverage Determination (LCD) and National Coverage Determination (NCD) be included?

    Professional Fee

    • Which specialties are to be included?
    • Which providers are to be included?
    • Will medical necessity for tests performed and services rendered against LCD and NCD be included?
  3. Determine the volumes for review

    Considerations can include specific volume per DRG, per coder, per coder per service type coded (for cross-trained coders). Etc.

  4. Choose a chart selection method

    Random, random from top MS-DRGs or SPR-DRGs, targeted by MS-DRG or APR-DRG or specific code, targeting of specific records.

  5. Determine if the review will be concurrent or retrospective

  6. Decide which payors are to be included

    Will your hospital or health care organization include all payors or specific payor types, such as Medicare only?

  7. Decide which dates of service are to be included

    Is it important to include the most recent dates of service, or dates of service from a specific quarter (Jan-Mar/Apr-June/July-Sept/Oct-Dec), etc.?

  8. Decide where the audit will be performed

    Is there a preference or advantage for considering remote vs. on-site?

  9. Plan time for the review

    Avoid scheduling coding audits during peak vacation times; ensure that your medical coding staff has adequate time set aside to participate in the coding audit process for reviewing the recommendations and responding to the auditor.

A trusted and proven vendor partner can go a long way in assisting your hospital or health care organization develop the best medical coding audit compliance plans based on your specific needs.

Click here to download a copy of "Improve coding and documentation deficiencies with nThrive’s on-going coding quality assurance program."

Have a question for an experienced medical coding specialist? Click here to ask questions or schedule a coding audit today!