Book excerpt: Why conduct coding audits

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

A coding audit may be conducted by internal staff or external entities (often by insurers paying for the care). When planning to implement an internal coding auditing program, the type of reviews, focus areas, and review fre­quency must all be taken into consideration, as each facet affects the level of staffing required to conduct the reviews.

The three primary goals for conducting coding reviews are to:

• Identify opportunities for coder and provider education
• Support the organization’s revenue integrity initiatives
• Enhance the revenue cycle by ensuring accurate claims are submitted and not subject to coding rejections and denials

If these goals are achieved, the organization should be successful in defending its coding practices with external auditors.

When we assess the accuracy of the codes assigned, we will be able to identify the competencies of our coding team to:

• Appropriately seek clarification through the creation and content of physi­cian queries.
• Distinguish clinical indications that identify the presence of an underlying and/or undocumented condition.
• Apply Coding Clinic, the ICD-10-CM/PCS Official Guidelines for Coding and Reporting, and other industry-recognized guidelines (Amer­ican Medical Association’s [AMA] CPT Assistant and CPT-4® Manual, National Correct Coding Initiative, etc.) to accurately code conditions and procedures. During this portion of the assessment, the auditor will also determine whether the coder is avoiding the coding of redundant con­ditions or conditions that are part of the definitive diagnosis or implied by the primary diagnosis, but able to distinguish symptoms or conditions that should be coded because they will support medical necessity.
• Select the principal diagnosis or reason for the encounter and properly sequence secondary conditions.
• Capture all relevant conditions that should be coded to accurately reflect the severity of the patient’s condition being treated.

Editor’s note: This article is an excerpt from The Essential Guide to Coding Audits.