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Coding Audits Ensure Accuracy, Support Clinical Decisions & Reduce Penalties

“In many cases, patients can be cared for effectively in an outpatient setting. Other times, proper patient care dictates hospital admission. Organizations are increasingly required to defend those positions, or risk reduced or denied payment. In such an environment, proper and thorough coding, alongside robust coding audits, is essential”, says Lisa Marks, RHIT, CCS, Coding Audit Director of nThrive.

“It's vital to make sure we're accurately reflecting that full clinical texture,” Marks says. “It's also vital to code all conditions, to have complete coding, to support resource consumption. All the test orders must be shown, because we want to make sure that we're avoiding the appearance of overutilization of services. Accurate coding also supports contract negotiations by showing the SLI or severity of illness.”

What’s more, she adds, proper coding can have an immediate impact on financials by reducing

penalties related to 30-day readmissions. That, coupled with audits who can catch problems throughout the coding continuum, can move the needle toward better, more accurate coding and subsequent revenue capture.

Coding audits capture savings, improve processes

“Coding audits can help capture every dollar and withstand an external audit by the government, payers… anyone that has the power to find, charge, or take money back,” Marks explains. “Audits can help prepare a facility for that external challenge.”

Audits have many parts, but chief among them should be complete documentation that reflects the actual patient severity and level of care. This promotes complete and accurate coding with documentation that allows the organization to stand up against any scrutiny avoiding fine charges and paybacks.

“We want to make sure that when we are challenged by that external agency, we have the expertise and experience in pulling the documentation together, presenting it, and then arguing the support of that documentation if it is actually challenged,” Marks explains.

It also is essential to keep a clear focus on the audit’s goal. The assumption is that the audit exists to improve reimbursements and reduce waste.  Both are true, but a well-run audit can accomplish much more in terms of operational excellence.

“The ultimate goal of a coding audit should be to achieve and maintain a complete and accurate database, and that’s often overshadowed by the reimbursement element,” Marks says. “We want to remember that it's not just about the reimbursement. The benefits of a complete and accurate database are far reaching.”

In sum, accurate and complete databases support:

  • An complete, detailed reflection of overall patient severity of illness and risk of mortality
  • Efficient resource consumption and length of stay
  • Improved comparison studies, profiling, and scorecards

“All of this accurate data supports minimizing the risk of regulatory exposure and also adhering to compliance regulations,” Marks says. “Audits are also valuable because accurate databases can play an important role in wellness initiatives.”

For information on nThrive’s many coding programs and solutions, click here.

Expert Bio:

Lisa Marks, RHIT, CCS, is the Coding Audit Director of nThrive. She leads a 35-member coding audit division, and routinely lends her expertise to the development of educational seminars and learning materials that span all aspects of the coding-audit process

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