Coding Audits Aimed at Clinical Documentation Improvement

With the 10th Annual Association of Clinical Documentation Improvement Specialists (ACDIS) Conference coming up this week in Las Vegas, Nevada, it is appropriate to remind healthcare professionals about the importance of medical coding audits and Clinical Documentation Improvement (CDI).

Coding audits aimed at clinical documentation improvement can enhance your facility’s performance in multiple ways 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 is the first step to success. You should select an external clinical documentation and coding auditing firm that provides highly-qualified CDI professionals and coding auditors 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 the key to improved 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 and CDI 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 audits and CDI work 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 poor 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. A good audit will formally report the documentation assessment and follow-up needed for CDI education opportunities.

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

When conducting an internal audit with the goal of CDI, 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 and CDI firm.