Preparing for an HCC Audit: Good Documentation is Key

by Rose T. Dunn, MBA, RHIA, CPA, FACHE

Good documentation is the best defense against a negative audit outcome.

We often find ourselves grousing about Dr. X who never documents something or Dr. Y who notoriously doesn’t enter her notes until the end of the week. Have your chatted with your peers in other practices to see how they have addressed similar bad habits?

What about the provider who treats patients with multiple conditions but only documents one condition? Have you researched his/her public profiles and those peers in the same specialties? This is an interesting way to give the provider feedback on how his/her profile compares to others in the same specialty and in the same community.

How often is formal education provided for your clinicians and physicians on best documentation practices? And how often are coding and documentation audits conducted and reviewed individually with the providers? Providers appreciate data—that’s how they work. We all like to know how we’re doing.

I’m interested to know if you provide feedback on denials that are documentation-related. How has that feedback been portrayed for the provider? What has been the reaction?


Fundamentals of HCC Coding
Complete and accurate coding for Hierarchical Condition Categories (HCCs) presents an opportunity for improved data quality and appropriate reimbursement. Learn how from nationally recognized HCC expert, Rose T. Dunn, MBA, RHIA, CPA, FACHE.



About the Author

Rose Dunn
Rose Dunn is the Chief Operating Officer at First Class Solutions, Inc., a healthcare information management leader since 1988. Rose is the author of “The Revenue Integrity Manager’s Guidebook” available from the National Association of Healthcare Revenue Integrity and other books on Coding Management and Auditing from HCPro. She engaged herself in ICD-10 more than 10 years before it was implemented. She is assisting Libman Education in the development of an HCC educational program. Rose holds a BS and MBA from Saint Louis University.

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