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.
Once an organization determines whether an audit will be prospective or retrospective, the next step is sample selection methodology. “Some organizations conduct a random selection of all chart types a coder has coded and then select the charts to be audited from that sample,” says Gabe Stein, executive vice president of GeBBS Healthcare Solutions. “Another sample selection method is a targeted random sample where they look at specific high-risk areas and high-dollar charts, for instance.”
Jacqueline Thelian, CPC, CPC-I, CHCA, president of Medco Consultants, says 10 random encounters from each provider are typically selected for review. “This is generally not a statistically valid sample, and the claims selected are usually prebill to avoid the potential of any paybacks relating to the audit and/or previous claims,” she says.
In a code-for-code audit, those codes that impact reimbursement are given twice the weight of those that do not. “Another perspective along the same lines is the full-record methodology, examining each record and only looking at mistakes that impact reimbursement,” says Sarah Humbert, coding and compliance manager at KIWI-TEK. “If there is a mistake with the diagnosis, for example, there is a reimbursement issue. With this method, the entire record is counted as wrong.”
Lisa Marks, RHIT, CCS, director of client audits at nThrive, says each methodology offers different benefits, recommends clients employ various auditing strategies to gain the best each has to offer. “For example, for quarterly audits, quarters one and three would be random, all payers, retrospective, while quarters two and four would be targeted, all payers, retrospective and include a targeted daily prebill audit,” she says.
Facility type determines the source documents required and the rules and regulations that must be followed. “When comparing different types of organizations—for instance, a community hospital with a trauma facility—a community hospital may lend itself to a random sample while a Level I trauma facility may lend itself more to a focused audit,” Stein says.
Marks adds another example of how facility type changes the equation. “A teaching university facility should have larger volumes and more frequent audits performed quarterly due to the higher level of complexity and broader range of different services it offers. Meanwhile, smaller facilities with smaller volumes have less frequent audits performed annually due to the lower level of complexity and more narrow range of service types offered,” she says.
Nevertheless, Humbert says facility type should not be an important factor when choosing an appropriate audit method. “I think the objective of the audit is more the key,” she says.
Marks says that standardizing auditing methodologies is difficult, given the variety of health care facilities. “There are so many nuances that are specific only to individual groups. Different groups have different challenges, documentation, and coding strengths and weaknesses—clinical complexities among them,” she explains. “Even within one facility, they should consider different chart selection methodologies, as how chart selection is performed can determine what you learn from the audit.”
But other experts believe that some standardization is possible. “Largely, it’s based on the objective of the audit,” Humbert says.
“You can have a consistent audit methodology—monthly, biannually—and then change up your sample selection methodology to achieve your desired results: improving coding quality and lowering compliance risk,” Stein says. “With an audit methodology, the first step is to decide whether you choose to audit by coder, by service type, or by facility—whatever your grouping is for the audit.”
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