Implement periodic external audits to ensure your claims are accurate and will hold up to payer scrutiny.
The year 2020 was unequivocally the year of healthcare changes. We had multiple ICD-10-CM, CPT®, and payer coding guideline changes associated with the COVID-19 pandemic. We had the new American Medical Association (AMA) and Centers for Medicare & Medicaid Services (CMS) guidelines for the 2021 evaluation and management (E/M) office visit codes. Don’t forget the delayed release of the Medicare Physician Fee Schedule (MPFS) final rule, followed by the new stimulus bill, which overturned some of the new codes provided in the MPFS final rule. And to top it off, the Department of Justice reported that it charged over 300 individuals for involvement in healthcare fraud, waste, and abuse schemes resulting in over $6 billion in false and fraudulent claims — the largest enforcement action in the department’s history.
With all of these recent events and changes in healthcare delivery, coding accuracy is more critical than ever. Having an active, robust audit compliance program is essential. Auditing your coders is an important part of ensuring quality and regulatory compliance for both hospitals and medical practices. External audits offer objective visibility into departmental operations, identify gaps in your coding processes, and uncover deficiencies and coding errors that an internal audit program may miss.
Quality Trumps Quantity
While both quality and maintaining departmental production standards are important to all organizations, putting quantity above quality will ultimately result in errors, denials, or worse. All of which takes more time to resolve than if it had been coded correctly from the start.
The only way to ensure quality is to perform an audit. As beneficial as an external audit may be, NO ONE likes to be put under the microscope. Having an external audit done can bring anxiety to any coder. Just the thought of someone else scrutinizing their coding quality while they strive for perfection and high productivity can bring on feelings of worry, agitation, or even fatigue. Industry best practices suggest that outside reviews will strengthen your future internal audits. And when done with the right approach, increased frequency and sample size, and a collaborative rebuttal process, they will strengthen the skills and confidence of your coders.
Approach Is Everything
Coders and the auditor should view an audit as a time to learn and strengthen both of their skill sets. Neither the coders nor the auditor can possibly know everything when it comes to the complexities each unique medical specialty brings. There will always be different opinions and interpretations. Both must approach the audit process with an open mind. Bringing in physicians and other providers into conversations can also deepen the understanding to an entirely new level. This approach of learning together will build mutual respect and trust, resulting in continual improvement.
Frequency and Size
Both the Office of Inspector General (OIG) and CMS recommend that all physicians and non-physician providers have their coding reviewed by an outside independent party who has the appropriate expertise in that clinical specialty. The purpose of these reviews is to obtain an unbiased evaluation to ensure coding accuracy. So why wouldn’t coders fall into this same recommendation? The question really isn’t why audit your coders. But rather, how often and how many dates of service should be reviewed?
According to Healthicity’s Annual Compliance & Auditing Benchmark Report, 82 percent of organizations conduct monthly or quarterly reviews on their coders.
The report goes on to state that 21 percent of these organizations select a sample size of 25 or more patient visits for each coder. Another 41 percent selects a sample size of 10-15 patient visits.
This suggests that most organizations understand the value of performing audits on their coders at a higher frequency and larger sample size than physician compliance audits. By performing frequent reviews with larger sample sizes, organizations will significantly lower their risk of ineffectiveness, reduce potential over/underpayments and lost revenue, and prevent non-compliance issues from recurring.
A coder audit should be a learning opportunity rather than a punitive process. As such, the coder’s voice must be the major player in the results discussion. It is crucial to allow adequate time for coders to review their results and be given an opportunity to defend their original coding decisions. Coders should want to be audited. By allowing this time and with the right approach, it will empower your coders to have healthy, productive conversations between other coders, auditors, and physicians. It will contribute to not only the coders’ growth and success, but also turn them into rock star coders.
There is no doubt that coder audits can be stressful. However, the right approach, increased frequency and sample size, and a collaborative rebuttal process will improve the overall quality, production, and success of your coders. The bottom line: Performing external audits on your coders will give your organization peace of mind knowing your claims are accurate, will hold up to payer scrutiny, and, most importantly, ensure proper payment.