Clinical Documentation and Coding Audits Can Improve Your Performance in Multiple Ways

Clinical documentation and coding audits can improve your facility’s performance and help you achieve the following goals:
  •  – Improve overall coding accuracy
  •  – Improve clinical documentation
  •  – Improve capture of patient acuity levels
  •  – Increase reimbursement
  •  – Reduce compliance risk from RAC, MIC and MAC
  •  – Reduce risks from incomplete or unclear documentation

Careful planning for your internal audit is the first step to success. You should select an external clinical documentation and coding auditing firm that provides highly-qualified coding auditors and CDI professionals to ensure you receive the best possible service. The company should have a nationwide reputation and their staff members should have undergone a stringent screening process to verify their skill level, education, experience, and level of professionalism. Their auditors should have five years of experience, at minimum, and be certified RHIA, RHIT, CCS, CCS-P, CPC, CPC-H, RN, PA, CDIP, CCDS or combination thereof.

Your facility should go into the audit with a clear understanding of the reason and purpose for the audit. The six goals mentioned earlier should always be kept in mind. Consistent auditing is key in order to improve clinical documentation and coding quality. You want to compare “apples to apples” in order to trend quality and provide educational opportunities.

In addition to defining the purpose, obtaining buy-in from senior leadership is a crucial part of creating an effective audit program. This is especially important if audits reveal unfavorable findings related to physician documentation. Chief medical officers must be on board to ensure that all physicians—even those who bring in the most business for the hospital—are held to the same standards with respect to achieving improvements.

Your audit should not be based purely on financial performance. Conducting a coding audit solely to increase revenue in a particular area could raise a red flag and will probably not yield the anticipated results. It is often assumed that incorrect coding solely causes decreased revenue, but the decrease could be due to other factors, such as clinical documentation or lower volume of cases.

Your facility’s auditing and monitoring should be risk-based — not driven by financial performance or a “check-off box”.

The focus and frequency of your coding audits—whether annual, quarterly, monthly, or concurrently — should be based on identifying risks and driving quality care. Conducting audits at random intervals is not helpful. You will not be reducing your overall risk, and you will leave yourself vulnerable by not looking at and evaluating the true risks.

Auditing the same areas each year is not beneficial either. Areas of risks are moving targets. They may not carry over year to year, quarter to quarter, or even month to month.

Hospitals are increasingly requesting internal clinical documentation and coding audits to prepare for ICD-10. This trend combines a coding audit with a more formal documentation assessment that deals with an assessment of the more granular ICD-10 coding system to highlight the need for individual physician education.

A good audit will formally report the documentation assessment and follow-up for needed education opportunities. This helps prepare for ICD-10 because of the ability to identify physicians who do not document correctly.

Ensure a thorough post-audit follow-up. If your facility doesn’t intend to follow through with audit results and take corrective action when necessary, the audit will be essentially useless and even potentially damaging to your organization.

When conducting an internal audit, consider the objective, scope, and number of records to be audited; then create a plan of action that includes enlisting the help of an experienced external auditing firm.