Best Practices in Coding Audits: Methodologies

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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About the Author

Libman Education
Libman Education Inc. is a leading provider of training for the health care workforce offering self-paced and instructor-led online courses designed and developed by leading industry experts in Health Information Management (HIM) and Medical Record Coding. Our courses are specifically designed to improve individual skills and increase the efficiencies and competencies of health care providers and institutions. At Libman Education, we understand the needs and challenges of a well-trained workforce and offer the right-mix of online education to ensure that the health care professionals are prepared to meet the challenges of the changing workplace.

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