The What, Where, & Why Of Coding Audits

April 1, 2021
April 1, 2021

Healthcare is and will always be about providing outstanding patient care. Today’s provider landscape is populated by more information and analytics than ever before in service to that goal, and coding plays a huge role in the data that is amassed, studied, and repurposed to provide that care and also maximize business operations.

“Central to the idea of good coding is assessment, which happens in the form of coding audits. And to get a sense of what those offer, it’s sensible to start by understanding what they are, and what they are designed to accomplish,” says Lisa Marks, Coding Audit Director of nThrive.

“A coding audit can be defined in lot of different ways,” Marks says. “Out of curiosity I Googled ‘coding audit’ recently, just to see what Google had to say. In doing so I found  that an ‘independent outside coding audit demonstrates that reasonable steps have been taken to ensure compliance, in the event of an audit,’ and ‘having an arm's-length independent coding evaluation helps prevent and reduce potential legal and financial compliance exposure.’”

Her research also turned up many articles pointing to the need for regular audits, a point she concurs with, while also adding that audits are best done when they can assess a specific issue and provide direction for going forward. And technology can be as much of a burden as a boon if not deployed correctly—not just in terms of the audit itself, but also the people engaged in the process, she adds.

“With advances in electronic health records, most audits today are performed remotely,” Marks explains. “The primary crime thoughthat exists with that remote approach is missing that face-to-face interaction between the auditor and the coder. Today’s technology does allow for webcam capabilities, so coders and orders can actually see each other. At nThrive, our auditors are set up to support webcam educational sessions. A lot of clients don't have the webcam technology or equipment on their end, but that is something to consider regarding audits—the possibility of setting up some webcam sessions between your external auditor and your coding staff for better engagement.”

The ‘where’ of an audit can define its eventual effectiveness

Now to the question of where an audit should be performed within the facility or system itself. Marks says the best benchmark for that would anywhere where coding could potentially impact billing and reimbursement or comparison studies.

“For example, we've got our hospital inpatients and the hospital outpatient setting, and we want to improve billing accuracy on injections and infusions. So, the audit could include all service types, all settings, all encounter visit types,” she explains, all of which would combine to create an audit that is rich in detail for a very targeted range of procedures that often create financial burdens on healthcare systems.

The ’where’ of an audit also informs its ‘why,’ Marks adds, pointing out that audits may be about uncovering financial savings opportunities at the outset, but can provide so much more insight and value.

“Often the primary focus is on reimbursement, and accurate coding can drive course corrections there, as well as an accurate case mix index or CMI,” she says. “Accurate coding also can decrease the number of rejections and denial and that's huge today. Accurate coding can decrease analysis rejections by avoiding inaccurate assignments. Making sure that those are all accurate will decrease those rejections in denial, and accurate coding also can decrease rejections in denials related to medical necessity admissions and testing services.

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


About Our Expert:

Lisa Marks, RHIT, CCS, is the Coding Audit Director of HealthStream’s partner, 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.