By Rose T. Dunn, MBA, RHIA, CPA, FACHE, FHFMA

A reader asked “Do you need to be a coder to be a coding auditor, and if so, what is the best path to take to achieve the goal of becoming an auditor?” I will break my response into two segments.

Do you need to be a coder to be a coding auditor?

In my opinion, yes, you need to have coded records, of all types, to be a coding auditor. Your experience as a coder should include having a thorough knowledge of the coding guidelines and Coding Clinic advice. You need to know where to look for diagnoses, understand clinical indications, and understand surgical procedures. To be competent in the use and code assignment of ICD-10 codes, one must have a thorough knowledge of medical terminology, anatomy and physiology, pathophysiology, and pharmacology. A person may have knowledge in these “ologies” but not a sufficient understanding or skill in applying the many coding rules that govern the assignment of ICD-10 CM or PCS codes.

A thorough knowledge of the “ologies” and understanding the coding rules are honed when one actually assigns codes after reading the clinical documentation in a patient record. Doing well on multiple choice and/or a few sentences in a scenario is not the same as reading the story of a patient’s condition and treatment regimen during the course of care.

While the course of care as described in the record is being reviewed by the coder, the linkage between laboratory test results, medications ordered, and the clinical conditions are demonstrated. If one has not coded, one may not see these linkages. Auditors who simply validate that the codes assigned by a coder are valid may miss the fact that other conditions should have been coded, a condition coded was included in another code, or that clinical indications may indicate the need to query a provider for further information or clarification.

Some individuals who have clinical expertise believe they can audit without having coded. Unfortunately, the lack of understanding of coding rules will be apparent. Clinicians often make subjective decisions; coders know that they cannot assume anything.

Finally, since I code infrequently, I sought input from my team’s top coding auditors for their input. This is what they had to say:

“Personally I would only want someone with coding experience to audit my coding. To audit, one needs to know coding rules, coding exceptions to those rules, Coding Clinic advice (those date back to the 80’s!) and understand why a coder might do certain things. While non-coders may audit certain components of a coding audit, such as medical necessity, present on admission, or discharge disposition, only coders understand what to code and when (or what not to code) from beginning of stay through discharge.”
–Dawn Bertels, RHIT, CCS, Senior Coding Compliance Consultant

“I believe it is beneficial to have several years of experience with coding in order to be an auditor. By having the coding background, you have actual hands-on experience with reviewing and analyzing chart documentation and knowledge of coding applications and guidelines. For auditing, there are other skills that are necessary, but I believe the coding background enhances your auditing skills.”
– Maria Brooks-Swims, RHIA, CCS, CCDS, CRC, Assistant Vice President, Coding and Compliance

My next article will offer my recommendations for the best path to take to achieve the goal of becoming a coding auditor.

 

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