by Carol Maimone, RHIT, CCS, CDIP
Performing internal audits can prove invaluable in preparing for external audits, improving overall quality and outcomes, and identifying needs for continued staff education.
External audits and initiatives cannot be avoided; they seem to be increasing in regularity and keep any department busy. Making use of the external audit results can assist in refining internal audit targets.
Experienced internal auditors responding to these external audits can use the information gained from them for many advantageous uses:
- Utilize provider-specific Medicare data statistics provided by PEPPER (Program for Evaluating Payment Patterns Electronic Report) to proactively identify and remediate for discharges/services that are vulnerable to improper payments. This data can help identify both potential overpayments as well as potential underpayments.
- Develop a strategy for responding to external audits. Developing templates or prepared rationale to respond to specific types of audits such as sepsis or acute respiratory failure which can assist with time spent as well as quality of appeal. Consider involving a physician liaison and CDI staff.
Monitor incoming audits and quality reports to improve overall quality such as:
- Benchmark facility against current clinical criteria
- Evaluating provider-specific areas for improvement
- Identification of patient-safety areas of need
Use information gained from internal audits and utilize them for staff education to improve future outcomes. For example:
- Additional query opportunities
- Identifying and support single CCs or MCCs that may be targeted
- Understanding of complex or new procedures
- Educate providers and other departments regarding documentation requirements
An internal auditing program will ensure a facility is prepared to handle the challenge of external audits on the horizon, improve quality and outcomes, and enhance staff education for a strong front moving forward.
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Carol Maimone, RHIT, CCS, CDIP, lives in Schenectady, NY and works as a medical coding auditor and educator with 20 years of experience. [email protected]