The Future of HIM Quality Audits

By Betty Schulte, RHIT, CCS, CCS-P, Director, Compliance & Quality Audit Services, himagine solutions
Twitter: @himagineInc

5 Reasons Why Coding & Documentation Audits Are More Important Than Ever

All health information management (HIM) leaders know that coding quality audits are critical. We can all agree the consequences of substandard coding – lost revenue, increased denials, and greater compliance risk – make the development of a comprehensive coding audit program a priority for healthcare providers of all sizes. Unfortunately, scarce resources and conflicting priorities force many providers to compromise their compliance programs. But now more than ever, audits of coding and documentation quality are critical to the success of healthcare providers.

  1. EMRs are moving to direct enter text and creating mapping to codes. While this may simplify the coding process for providers, the risk is the codes selected will lack the specificity needed to ensure proper reimbursement and compliance. Regular auditing will ensure that coding by providers and the automated systems are accurate and specific.
  2. Increasing budgetary constraints make optimizing reimbursement a priority. And while an audit program may be viewed as a cost, a well-designed program can yield a significant return on investment by reducing denials and minimizing over- and under-coding. Central Learnings Second Annual Nationwide coding contest found that the average loss per inpatient record was $754. Ensuring that accurate revenue is captured more than pays for an ongoing audit program.
  3. Specificity is the key to accurate reimbursement, making documentation audits just as important as coding audits. Coding audits have become common practice, but with the increased specificity of ICD-10, audit programs focused on improving the documentation needed to accurately code must be implemented. Both inpatient and outpatient clinical documentation improvement (CDI) audits need to be performed not only to review the current program and query integrity but ultimately to provide documentation improvement education to providers.
  4. Increased attention on risk adjustment will lead to greater focus on ensuring accurate hierarchical condition category (HCC) capture. Nearly 58% of HCCs are also major complication or comorbidity (MCC) or complication or comorbidity (CC) codes in an inpatient setting. Because of this overlap, inpatient coding can help to prompt better coding in the outpatient setting, which provides a more well-rounded picture of the patient for risk adjustment. Diagnoses identified in the inpatient setting can be captured and passed to the patient’s primary care physician to increase HCC capture and improve the risk adjustment factor.
  5. Audit customization across facility types and payer requirements will be key. Health systems today encompass a wide range of settings – from acute care settings to critical access hospitals, physician groups to a variety of outpatient settings. Each facility type needs to be audited – and results provided – based on the factors that will be most useful for improving reimbursement and compliance. For example, a critical access hospital does not need audit results based on MS-DRG reimbursement, but rather a cost-based reimbursement model.

And let’s not forget, ICD-11 is looming on the horizon. As we learned with the transition to ICD-10, ongoing audits help to sustain quality so getting your audit program in place now will make the move to ICD-11 go more smoothly.

While it may seem daunting, building a comprehensive coding and documentation audit program is crucial in today’s environment of increased government scrutiny on top of razor-thin margins and downward pressure on reimbursement. Whether you build your program internally or partner with a firm like himagine that can manage an audit program on your behalf, the benefits of a comprehensive quality assurance program far outweigh the costs.

This article was originally published on himagine solutions and is republished here with permission.