Internal Audits: Managing to Get the Most From the Process

By Cari A. Greenwood, RHIA, CCS, CPC, CICA, Education Specialist

When you manage a team of coders, maintaining coding accuracy is one of your responsibilities.  Coding audits come with the job. Regular quarterly or targeted internal audits can give you a realistic picture of your staff’s skill levels and competence and are a valuable tool for ensuring that the work your coders do is correct.

How can you ensure that you are getting the most from your internal auditing process? We have some suggestions:

Change the Mind Set. The fact is, we all make mistakes. Positioning your internal audit as an educational tool will help your staff see the audit as an opportunity to correct themselves and improve their skills rather than as a critique.

Encourage Your Coders To Push Back. It is human nature to be defensive when you are told that you did something incorrectly. Due to their achievement-orientated nature, this can be especially true of coding professionals. If your coders disagree with the findings of an audit, give them the opportunity to make the case for why their approach is more correct. They may be right and if not, going through the exercise of attempting to prove that their code selection is correct will improve their critical thinking.

Appreciate the Ambiguity. Because coding is complicated and because coders possess differences in perspective and experience, an audit may reveal that two equally skilled coders disagree about the right way to code something. This is not necessarily a bad thing. Keeping an open mind and seeing a coding scenario from a different point of view allows a coder to think more flexibly when dealing with new or unfamiliar coding situations. Being able to see and analyze a problem from many angles lends itself to better coding accuracy overall.

Take the Long View. Think of internal auditing as a process instead of an event. Benchmark your results as a snapshot in time of current skills and issues. This snapshot can be used as a baseline for measuring future progress. Then use the results from subsequent audits to actively manage your staff and improve their results over time.

Validate Your Investment In Training. Use your hard-won “good” audit results to reinforce that your staff’s sharply honed skills were worth the investment in terms of energy and resources. Use any less than ideal results to identify topics for targeted training or to justify up-skilling for specific staff members. You will have another chance with the next audit to show why that investment was worthwhile.

Take the Opportunity To Adjust Your Staff. As manager of the team, you decide whether to invest more time and money in improving the skills of specific staff members. The results of an internal audit may demonstrate that a different job within your organization might be a better fit. Audit results give you a tangible yardstick to start a discussion.

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About the Author

Cari A. Greenwood, RHIA, CCS, CPC, CICA
Cari Greenwood is an Education Specialist with Libman Education responsible for developing courses that engage the adult learner consistent with the demands of coders, auditors, and CDI professionals at organizations nationwide.

With more than 17 years of experience in health information management (HIM), Cari is a well-rounded HIM professional who holds RHIA and CCS credentials from AHIMA, a CPC credential from AAPC, and is an AHIMA-approved ICD-10-CM/PCS Trainer and an HFMA-Certified Inpatient Coding Auditor. Through her 11 plus years as a coding educator, Cari has gathered insight and information derived from her experience working with individual professionals and teams as they pursue advanced HIM training.

Cari’s HIM expertise combined with her passion for teaching is the foundation for her career as an author and presenter specializing in coding and auditing education. As Cari has stated: “The challenge facing anyone working with data and code sets is that it requires regular study to stay current with the evolutions in healthcare and able to accurately and efficiently do the work required of an HIM professional. A strong foundation of core skills and knowledge is the beginning, not the totality of an HIM education, there is always more to learn.”

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.

One thought on “Internal Audits: Managing to Get the Most From the Process

  1. Vera Odoms, RN CDI Mgr - February 3, 2021 at 4:41 pm

    Refreshing perspective. V. Odoms, RN, CCDS