Medical auditing is a systematic approach to peer assessment of medical treatment that identifies and implements possibilities for improvement.
Almost any aspect of healthcare can be audited, although most audits focus on payer payment systems to assess compliance with payer guidelines, federal and state legislation. The medical audit plays an important part in a healthcare organization’s compliance plan by finding faults and designing corrective procedures to eradicate them. These compliance difficulties can also influence your business line, your organization’s reputation, and most critically the kind of care you provide to your patients.
Internal Coding Audit
Employees from the healthcare institution undertake an internal coding audit. In larger healthcare companies, this may imply that employees of the audit department check coding systems and processes. In smaller businesses, this responsibility may be assigned to a medical coder who has been trained to conduct audits. Internal auditors can evaluate compliance requirements by examining areas with high compliance risks. Finally, auditing areas where previous audits revealed mistakes can be beneficial.
External Coding Audit
Professional medical coding audit businesses conduct third-party medical coding audits. Internal coding audits are valuable, but external audits offer the advantage of being objective. Furthermore, organizations specializing in this process can frequently provide advanced medical coding and auditing services that go beyond what a healthcare company can do internally. Healthcare organizations are not required to execute the auditing process when subjected to an external code audit, but they can prepare for the procedure and its outcomes. Organizations might set objectives and goals before the audit. The job of external auditors can then be tailored to the organization.
Importance Of Medical Audits
- Medical auditing undertaken by or on behalf of the provider organization is critical because it prevents coding and billing problems.
- Medical auditing addresses ignorance by exposing areas of noncompliance, and ignorance is a liability.
- Examine the quality of care delivered to patients.
- Educate providers on proper paperwork.
- Check if the organization’s policies are up to date and effective.
- Improve revenue cycle management.
- Ensure that adequate revenue is collected.
- Protect yourself from government and payer audits, malpractice lawsuits, and health plan denials.
Coding Audits in Seven Steps:
Determine whether the coding audit will be performed by internal or external auditing staff (or both); choose those with the necessary experience and qualifications.
- Create a coding audit scope to calculate the volume of records (number of encounters) and specifying types (inpatient, outpatient, physician office, etc.) to ensure that the audit size is appropriate and the time duration is sufficient. Determine whether the audit will be random, focused or a combination of both. Define a coding deviation or error to avoid uncertainties at the end of the audit.
- Choose whether the code audit will be pre-bill/prospective or retrospective (after the claim/bill has been paid). Check that the diagnosis and procedure codes (ICD-10-CM/PCS and CPT) are audited.
- Request inquiry forms or templates, coding policies and procedures. Also, demand the coding process workflow (document) to understand the procedure and data flow fully.
- Conduct chart review and procedure (auditing function). The claim/UB will often be used while conducting the review (reviewing the medical record documentation and clinical coding). Record the results on an audit worksheet tool, and offer a reasoned response and reason for the findings (quote official sources).
- Make an audit summary (including patterns and trends) and suggestions (include the next audit time frame). Include a written narrative summary report, a verbal (virtual) presentation of the audit report, and so on. Give time for the coding staff to analyze the results and provide comments and responses (this should be done within 7-8 business days).
- Take corrective actions and settlement of coding problems (variances): this covers any rebilling of overpayments (rebill within 60 days of overpayment confirmation) or underpayments caused by clinical coding changes. Record and certify the completion of this process. If there are fundamental patterns or trends, you may need to consult your regulatory and legal teams to decide on future corrective actions (refunds) or audits.
- Conduct training for the following groups: HIM coding personnel, CDI staff, and doctors; consult with physician liaison. All of them should receive helpful education.
Conclusion
Regular audits to provide input, identify concerns, and check compliance can help to enhance the overall performance of your medical coding. Proper coding on existing claims decreases the possibility of modifications and denials, allowing work time to be used more efficiently. Precision and compliance are desired corporate practices that aid in claim adjudication timely.
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At first glance, internal and external audit quality management appear similar, they are in fact functionally different in approach and serve entirely different purposes, even though they both may be conducted within an organisation.
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