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.
In an effort to ensure coding accuracy and regulatory compliance, the Centers for Medicare & Medicaid Services (CMS) and the Office of Inspector General (OIG) recommend that health care providers routinely enlist independent parties to audit coding practices. Many health care organizations welcome these audits as a way to obtain feedback regarding their coding programs, in large measure to improve quality.
Although the goals may generally be the same, coding audits can differ in several ways, including methodology type. 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.
“Prebill audits take more focus and dedication to the timing of the audit to avoid a negative impact on accounts receivable. However, no rebilling is necessary, and the learning opportunity is immediate,” explains Lisa Marks, RHIT, CCS, director of client audits at nThrive. “Postbill audits allow more breathing room with the audit workflow timing, but then necessary corrections require rebilling and delay learning. Additionally, rebilling for higher reimbursement must be performed within a certain window depending on the payer, so there is a time constraint when correcting mistakes resulting in higher reimbursement.”
Shannon O. DeConda, CPC, CPC-I, CPMA, CEMC, CMSCS, partner and founder of DoctorsManagement and president of the National Alliance of Medical Auditing Specialists, says, “A lot of places like retrospective audits because they don’t want to pend claims. But then they don’t always like that type of audit because they have to correct billing errors. CMS could see it as fraud if the corrections aren’t made in a timely fashion. The prospective audit helps alleviate that problem.”
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