What areas can a healthcare facility investigate to determine what types of coding audits to conduct
If your facility is struggling with developing a properly risk based internal audit plan within resource limitations, you are not alone. With the myriad of changes that happen each year in healthcare and the subsequent risks that are presented, it is imperative to develop an internal audit plan that fits the needs of your organization. Show An internal audit plan is simply a plan to provide a review of an organization’s processes and procedures over selected areas to ensure financial and operational controls are in place and assure they are mitigating risk for the organization. In healthcare, a common key component of any internal audit plan is compliance-related risks. The Office of Inspector General (OIG) has stated there are basic elements when constructing the compliance portion of your internal audit plan, one of which is conducting internal monitoring and auditing focused on billing and coding issues through performance of periodic reviews. This component of the compliance plan can provide documented evidence to the OIG in their assessment of whether reasonable efforts were taken to avoid fraud and abuse. Three Main Types of Risk
Basic Steps for Billing and Coding AuditsWe have created a checklist below to ensure best practices are met:
The determination of who will perform the audits is an internal organizational decision. Some organizations have the resources to perform quarterly audits as mentioned above, and ensuring the personnel have the proper credentials and have some level of independence is important for an effective audit process in this area. For other organizations, having the proper resources available is not feasible, in which case, an external resource can be engaged. In other cases, a blend of both may be more appropriate. The organization can engage with an audit partner to assist when needed or for specific types of audits. Determine the Frequency of the
Reviews Establish
an “Accuracy” Goal An accuracy goal gives the organization some parameters to reach towards. Once audits are completed, these accuracy goals will allow for prioritization for follow-up audits and assist in determining where educational resources should focus. Each area identified in the review should be assigned a risk category based on severity. Here is a suggested guide:
Establish the Audit Size As noted, quarterly audits of randomly chosen encounters/cases are considered best practice. However, depending on the size of the organization, including all outpatient hospital claims in the population sample will likely be unrealistic. Narrowing the focus to specific areas—the Emergency Department, encounters or a specific type of high volume surgery, for example—may be an option based upon the situation. The focused areas/topics can be planned out for each quarter in advance while allowing flexibility in case an area of concern arises during the audit period. Selection Process
Other methods of choosing cases could include the following:
Flexibility should also be allowed for new service lines that are starting within the organization. An evaluation of the coding as well as a review of the claim should be performed to ensure that all elements of the coding and billing are processing correctly. Issue a Report of Findings Once an initial report of findings has been reviewed and shared with the applicable departments, the internal audit team, working with the compliance department, will want to examine the findings and identify any trends or errors that require urgent attention. For example, if a department is billing for infusion services without documenting start and stop times, a focused review may need to take place sooner, rather than later. There should be some flexibility built into the internal audit plan to allow for these types of focused reviews. However, action plan and remediation should also be established to ensure appropriate and timely resolution of issues based upon degree of risk in the area, and these action plans should be followed up on to ensure risk areas are appropriately resolved. In our experience, a 95% accuracy rate is required when under a Corporate Integrity Agreement. It’s best practice to apply this same level of accuracy when determining the organization’s acceptable threshold for error. If the findings of the review show less than a 95% accuracy rate, procedures should be in place to address the issues noted. Oftentimes, an action plan outlining the issue and recommendations can serve to engage the key stakeholders, establish deadlines and provide a roadmap with accountability for issue resolution. An example action plan may look like this:
In the example above, certain findings may encompass solely the coding team while other findings may pertain to a different department. It is not unusual for multiple departments or areas to overlap with respect to billing and coding responsibility for certain pathways. Therefore, it is important to include all the relevant parties in the process early, along with input on finding, resolution and action plan for remediation. In conclusion, we believe a partnership approach between the organization (compliance department) and the internal audit team is essential. Whether one leader is responsible for both areas or separate leaders are working together, communication is key. Internal audits can identify potential risk areas and can help to recommend improvements to mitigate risk. Organizations are encouraged to perform routine internal audits to identify opportunities and provide staff education. Recorded Webinar What are the types of coding audits?Coding audits can be retrospective, which is a review of submitted claims, or prospective, an analysis of prebilled claims. They can also be random, targeted, or a mix of both, and a code-for-code or full-record analysis.
How do you conduct a coding audit?Step 1: Determine What Types of Records to Review.. Step 2: Determine Volume of Records and Frequency to Review.. Step 3: Analyze Results.. Step 4: Corrective Action and Training.. Step 5: Get a Fresh Set of Eyes. CMS and the OIG recommend regularly having your coding audited by an outside reviewer.. What type of audit is the most common in healthcare?Random Audit
A random audit is one of the most efficient and commonly used audit types, designed to get a glimpse of the medical organization and the way it functions. The examination is done on an ad-hoc basis and does not have a known scheduled date.
Why are coding audits performed?Medical coding audits, both internal and external, ensure that healthcare organizations have the proper policies and procedures in place to achieve quality medical coding. Regular audits can reveal inaccuracy issues, such as outdated codes or even fraudulent billing.
|