Comprehensive Healthcare Auditing Services
The HHS Office of Inspector General (OIG) recommends that healthcare organizations perform a medical coding audit annually. The OIG also suggests that organizations implement routine monitoring and auditing processes. Audits can depend on many factors such as regulatory updates and staff turnover. Most healthcare facilities perform monthly audits throughout the year. Medical audits can be random or focused on areas such as office visits, consultations, Emergency Department, inpatient visits, and dental just to name a few. Our experienced auditors will evaluate documentation for accuracy and compliance. Findings often help improve claims processing, reduce rejections and/or denials, decrease incorrect coding issues, and improve provider compliance. Audits can help prevent a costly carrier payback by ensuring claims processing is compliant.
Our Auditing Process
We take a structured approach to auditing, ensuring transparency, accuracy, and strategic improvements for your healthcare organization.
Step 1: Initial Consultation & Assessment
Our process begins with a phone consultation to understand your needs, objectives, and any specific concerns related to coding and compliance. Whether you need an annual compliance review, a focused audit on a specific issue, or an external resource for internal compliance efforts, our auditing services are tailored to meet your needs.
Step 3: Quality Control & Compliance Verification
Our audit team strives to meet compliance standards by following the Official Guidelines for Coding and Reporting developed by the American Medical Association (AMA), American Hospital Association (AHA), Centers for Disease Control (CDC), National Center for Health Statistics (NCHS), the Centers for Medicare and Medicaid Services (CMS) and published by the American Hospitals Association’s Central Office on ICD-10-CM quarterly newsletters, formally known as ‘Coding Clinic,’ as well as CPT Assistant published by the American Medical Association.
Our team works collaboratively to ensure audit findings are consistently applied. We follow a multi-tiered quality control process to verify the accuracy of coding, billing, and documentation compliance.
Step 5: Post-Audit Consultation & Education
Upon completion of the audit, our clients receive:
- An informative discussion reviewing the audit findings and key areas for improvement and how to address them properly
- An educational plan for providers, coders, and/or billing staff to support future coding and billing accuracy while supporting compliance standards
Step 2: Comprehensive Chart Review
Certified and experienced auditors will conduct a detailed review of selected medical records to ensure, at a minimum:
- Evaluation and management levels are supported per documentation for medical decision-making or time-based coding.
- CPT/HCPCS/Modifier code accuracy and proper reporting
- ICD-10-CM coding accuracy and specificity to ensure correct diagnosis coding
- Charge capture validation, ensuring all billable services are documented and reported.
- Edit review for unbundling
Step 4: Audit Findings & Recommendations
Each audit includes a detailed written report outlining the following:
- Identified coding inaccuracies with information-enriched rationales
- Documentation enhanced opportunities, when identified
- Areas of potential compliance risk along with corrective actions
- Recommended process and documentation quality
If requested, we can provide a financial impact analysis showing how coding variances affected revenue based on audit results.
FAQs
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1. How do coding audits keep providers and hospitals compliant? Coding audits play a vital role in ensuring that providers and hospitals remain compliant with various regulations and standards in the healthcare industry. Audits can bring awareness to many areas, such as identifying errors and inaccuracies, ensuring adherence to guidelines is being met, identifying fraud and abuse risk areas, and recognizing opportunities and/or inaccuracies in documentation practices. By implementing coding audits, providers and hospitals can maintain compliance with regulations and enhance the overall quality of care and financial stability within their organizations.
2. In what way do coding audits contribute to staff development and training?
Coding audits highlight areas where coders may need additional training or support. By identifying knowledge gaps, hospitals can provide targeted educational resources, resulting in a more skilled coding team and improved accuracy in coding practices.
3. How can coding audits affect compliance with healthcare regulations?
Regular coding audits help ensure that medical coding practices align with current regulations and guidelines. This proactive approach reduces the risk of non-compliance penalties and legal issues, fostering a culture of accountability and adherence to standards.
4. What long-term benefits can providers and/or hospitals expect from coding audits?
Coding audits provide a comprehensive review of coding practices over time, allowing hospitals to identify trends and systemic issues. This can lead to enhanced training for staff, improved compliance with regulations, and stronger overall coding practices, which benefits the organization in the long run.
5. How do coding audits improve patient care?
Coding audits ensure that patient records are accurately maintained, which enhances the quality of care. Accurate coding leads to better data for patient outcomes, allowing hospitals to analyze treatment effectiveness and improve clinical practices.
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