by Susan Chapman
Republished with permission: For The Record Vol. 30 No. 1 P. 10
Susan Chapman, a Los Angeles-based freelance writer, interviewed auditing firm leaders to share their thoughts on best practices in coding audits.
Shannon O. DeConda, CPC, CPC-I, CPMA, CEMC, CMSCS, partner and founder of DoctorsManagement and president of the National Alliance of Medical Auditing Specialists, explains the issue with defining accuracy in coding audits: “The OIG recommends that physicians maintain an accuracy rate of 95%. Shouldn’t we then expect coders and auditors to be able to maintain a 90% to 95% accuracy rate as well?”
“When you look at documentation guidelines deep down, there are no true definitions—they are guidelines and not rules. Therefore, they have now created gray areas within documentation, such as in the history of present illness [HPI]. There are no definitions of each element such as quality. Organizations need to create a standard definition for not just quality, but all of the HPI elements to create standardization within your own team.”
“You have to have a unilateral answer and scoring technique for not only the coders and auditors but for the providers as well. Otherwise, it’s like driving down the interstate without knowing the speed limit. I know in general what the speed limit may be, but I can’t obey the law if I don’t know what the law is. When claims go into the carrier, they say it’s right or it’s wrong even if they have no published standardization of these definitions and it becomes one huge argument over interpretation of a lot of people’s findings. It can get convoluted if you don’t have internal policies within the organization.”
Sarah Humbert, coding and compliance manager at KIWI-TEK, believes accuracy can be viewed more subjectively. “Often you have to take into consideration a facility’s guidelines and procedures plus ICD-10 and CMS coding guidelines. There are some facilities that want everything captured, including secondary codes. Therefore, accuracy depends on the facility you’re auditing and which items they want to be captured,” she explains.
“In general terms, accuracy is precise performance of a task that is free from error. However, coding is too complex to cleanly fit into this definition,” explains Lisa Marks, RHIT, CCS, director of client audits at nThrive. “Coding can be accurate based on the existing documentation; however, the documentation could be incomplete, resulting in inaccurate coding based on the patient’s actual and true clinical picture.
“The codes assigned by the coder may be accurate, but the coder failed to assign numerous appropriate codes, which results in incomplete coding,” Marks continues. “Some would define incomplete coding as inaccurate. In this way, coding can be very subjective and open to interpretation of the guidelines and the documentation leading to differences in coding. There are times when a scenario can be coded in two different ways and both are correct.”
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