Preparing for an HCC Audit: How to Address Denials

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

Hierarchical condition category (HCC) audits can encompass a variety of topics such as incorrect coding, overcoding, and even billing issues such as excessive denials for one thing or another or duplicate claims.

If you are like many healthcare organizations, you are getting slammed with denials for everything from whether that Total Knee Arthroplasty (TKA) should have been done as an inpatient vs. outpatient to whether there really are sufficient clinical indicators to apply the malnutrition code regardless of whether the Emergency Department physician, attending physician and/or dietitian have documented it.

So, how are you addressing these denials? In general, a similar process needs to be in place for audits of your physicians’ claims and the hospital’s claims of Medicare Advantage patients.

Here are a few steps to consider:

  • Where do the denial or audit requests go? To Health Information Management? To Patient Financial Services? To someone else?
  • How quickly are those requests sent to you, the holder of those records?
  • Do you have a process established for receiving and processing records that are subject to an audit?
  • Do you just copy and send those records to the payer or audit firm working for the payer?
  • Does anyone see the requests other than your copy service or copy team?
  • Are these requests routed through your coding supervisor to validate the content, recheck the coding, and ensure all the pieces of the documentation are in the copied record being sent to the payer/auditor?

I’d be interested in hearing from others on how they handle audit lists from payers and if you are seeing any common conditions being audited, especially for physicians, but we want to hear from hospitals and other healthcare facilities, too.


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.

Comments are closed.