How To Create & Manage A Comprehensive Coding Audit

April 1, 2021
April 1, 2021

“A well-run coding audit can go a long way towards improving operational efficiency — if it’s done properly and with an eye toward all the goals it should achieve. That’s why planning and preparing are major steps that shouldn’t be rushed,” says Lisa Marks, RHIT, Coding Audit Director of nThrive.

According to Marks, there are some basics every audit should cover:

  • Defined Goals
  • a Specific Scope Outline
  • Frequency
  • Volumes
  • Chart Selection Methodologies
  • Timing
  • Payer Types
  • Risk Basis

“There’s a lot to think about and a lot to consider in preparing for a coding audit,” she says. “So first determine the primary goal. One of the most important tasks to an audit is to determine what your primary goal is — and communicate this to the auditor. This will help drive the other audit-preparation decisions and set you up to have a successful audit that meets your needs and expectations.”

Goal setting drives audit efficiency and produces better outcomes

To get there, she says, ask some basic questions: What are the primary goals? What do you want to learn? What do you want to achieve from a coding audit?

“For example, do you want to determine the overall accuracy of coding? If yes, do you want to determine this across the entire patient population, or just across the Medicare population?  Answering this can help drive decisions regarding which records are selected for the audit,” she explains.

Other areas to explore:

  • Identify areas of compliance risk
  • Check opportunities for improved reimbursement
  • Assess overall accuracy of individual coders
  • Focus on the coder or the provider
  • Focus on finding educational opportunities for coders and providers

“Determining your primary goal can drive decisions on the audit frequency, the scope, the volumes, and on the charts-collection methodologies,” Marks adds. “For example, if you wanted to cover all of these goals, a small, one-time audit of 30 to 40 encounters is not going to cover it. You're going to need a larger volume reviewed and would likely need to set up several separate audits to cover the various different goals.”

Once those goals are set, it will be time to explore the audit’s scope so that it can be managed efficiently. That will mean assessing whether it’s an inpatient or outpatient audit, or perhaps both, depending on the identified need and information being sought. Once that population group is identified, then it’s time to look at what types of services to be included in the review, as well as an understanding of the complexities around any or all of those services. The same goes if provider education is to be included as part of the analysis and results, because educating providers is very different than educating coders, Marks notes.

Determining the frequency or audits and reviews will vary by facility, and certainly by service. Different organizations choose different intervals, from daily to monthly, quarterly, semiannual and even annual, depending on what’s being assessed. Whatever the case, identifying clear goals and then creating a targeted list of ideal outcomes will help any audit achieve the desired outcome and provide the vital information a provider needs to ensure the best patient care alongside maximum operational efficiency.

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



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.