Tip: Conducting thorough compliance reviews through coding audits

by Rose T. Dunn, MBA, RHIA, CPA/CGMA, FACHE, FHFMA, CHPS

Coding reviews provide an opportunity for you to conduct a thorough compliance review that not only addresses other components of the coding process but also the integrity of the patient’s record. Some of these elements include:

Accuracy of present-on-admission (POA) assignment: If a condition was present at the time of admission, then the organization may not be faulted for it in the quality measurement system, and reimbursement should remain as anticipated. However, if a condition arises during an encounter, such as a pressure ulcer or never event, reimbursement could be decreased accordingly, and the quality measurement system will reflect the situation arising on the organization’s watch.

Presence of documentation conflicts (directional, condition, etc.): Identifying this situation (e.g., radiology exam states left lung nodule, but the surgeon’s note states right lung nodule) speaks to the integrity of the data in the patient’s record and could identify the need to focus on support services such as transcription. Additionally, if documentation conflicts are caught concurrently, a never-event or patient-care error may be avoided.

Use and misuse of copy-forward functionality: The copy-forward functionality can be beneficial for clinicians in capturing a complete description of a patient’s condition; however, it can be misused. An example I experienced was when a resident used the copy-forward functionality for 17 years of radiology exams. This obviously added bloat to the record and provided no added value.

Using the copy-forward functionality for a complete prior encounter to serve as the only documentation for a current encounter could be considered a fraudulent practice and explains why copy-forward is one of the issues included in the Office of Inspector General’s Work Plan.

Lost clinic data integrity and revenue integrity opportunities resulting from unanswered queries or queries not issued: As inferred, this situation would occur when a physician query was not issued or has gone unanswered. If the query had been issued or answered, there may have been more specificity in describing a condition or procedure that may have resulted in a higher-weighted hierarchical condition category (HCC) or DRG.

The need to modify e-forms and/or templates: When the coding auditor notices a trend with one or more physicians failing to provide a certain element required for coding, such as chronicity it may be added to the e-form or template as a way to prompt the physician to select acute, chronic, or other choices.

Another example is when the physician does not complete all fields of an e-form or template. In this situation, the auditor may suggest to information technology that one or more fields must be required fields.

Dating, timing, and signing practices: Particularly important for hierarchical condition category (HCC) audits is attention to the Risk Adjustment Validation audit criteria. This includes having a valid clinician signature, credentials, date, and time on each piece of documentation used for coding purposes.

Abbreviation usage: Use of “do not use” abbreviations as well as abbreviations that have not been approved for use by your organization can be assessed during an audit. This is another add-on that often falls on the shoulders of coding specialists. Since the coding specialists are reading the record, they often see abbreviations being used that may not be on the approved abbreviation list or may be an abbreviation that is on the “do not use” list. These cases should be flagged. However, the same should occur when the coding compliance auditors are reviewing records and their observation of these unorthodox uses should be tracked and reported.

Presence of more than one patient in a record: Observations of mixed files should be reported to the compliance department, privacy officer, and release of information department at the hospital. The privacy officer should be notified if the record had been released to anyone, thus presenting a breach for one of the patients. The situation is reported to compliance to assess whether patient care may have been negatively affected by the mixed patient information.

Presence of mis-scanned or poorly scanned documents: This last item is similar to the mixed-patient record issue. If another patient’s document was mis-scanned into the record or if a document was scanned to the wrong area of the patient’s record, it may have patient care implications. If there is a quality issue with the scanning, such as the documents are skewed, upside down, without patient identifiers, or not clear, there may be patient care implications. Both situations may require additional education for the scanning technicians.

Coding compliance audits cannot cover each of these points in a single audit.

Ideally, the topics will focus on issues that are frequent or require reassurance. Repeated denials for the sequencing of principal diagnoses may be alarming, but an audit may reveal that the coding specialists are doing their best to comply with the various coding guidelines. However, some coding audits should be routinely scheduled to assess the status quo, that is, whether the coding is being done accurately and completely for a random sample of cases, regardless of the diagnoses or clinicians involved.

In essence, the objective of conducting coding audits should be to ensure the completeness and accuracy of coding and coding-related processes as well as to identify any issues with the integrity and completeness of the documentation. While many audits are performed solely to improve reimbursement, when audits have a purpose of improving performance, improved reimbursement may occur by default.

Editor’s note: this article originally appeared in JustCoding and is excerpted from JustCoding's Essential Guide to Coding Audits by Rose T. Dunn, MBA, RHIA, CPA/CGMA, FACHE, FHFMA, CHPS, with contributions from William L. Malm, ND, RN, CRCR, CMAS.