Coding Audits and Denial Management
New research claims the typical health system risks $4.9 million each year due to claims denials. Preventative action is critical and audits are a practical approach. Whether to validate code assignment, check DRG selection or review coding compliance, H.I.M. ON CALL’s expert auditors deliver an unbiased view of quality and accuracy. Each audit is tailored to meet the client’s specific needs and expectations.
5 Steps to Fewer Denials
Kick-off Meeting: Onsite event to determine the most cost-efficient, impactful audit scope and methodology.
Target Selection: Identify specific focus for each audit or review including high-risk diagnosis and DRGs, principal diagnosis, principal procedure, and specific CC or MCC conditions.
Validation Review: Complete validation of all diagnosis code assignments, procedure codes, sequencing and code specificity to ensure compliance with correct coding rules and latest guidelines. Validation (retrospective or concurrent) of all DRG (MS/APR) assignments is also provided.
Opportunity Improvement Report: Define all documentation improvement and coder education opportunities including a comprehensive report of all findings and recommendations.
Customized Education: Education and training program options are also available to address specific coder knowledge gaps and clinical documentation insufficiencies identified throughout the project.
After the Audit: Focus on ICD-10 Specificity and Financial Impact
ICD-10 elevated the need for specific code assignment. Any use of unspecified codes will most probably result in claims denials and recovery contractor reviews.
Upon completion of H.I.M. ON CALL’s audit and validation of a satisfactory rate for DRG assessments, our expert team takes a closer look at any unspecified diagnosis or procedure codes uncovered during the review to:
Define unspecified code rate
Uncover possible causes and opportunities for improvement
Report missed query opportunities
Determine financial impact
Recommend targeted education for coders, CDI specialists and physicians
Audit Program Checklist
Here is specific data that our auditors identify and use to summarize clients’ findings:
|Client Deliverable||Inpatient Audit||Outpatient Audit|
|HOC Reviewer ID||X||X|
|Number of records reviewed||X||X|
|Number of changes||X||X|
|APC accuracy rate||X|
|E&M Level changes||X|
|Patient Status changes||X|
|Severity of illness changes||X|
|DRG accuracy rate||X|
|Principal diagnosis accuracy rate||X|
|Overall coding accuracy rate||X||X|
|CC/MCC accuracy rate||X|
|Reason for change||X||X|
|Summary of errors by ICD-10 CM chapter||X|
|Summary of errors by ICD-10 PCS chapter||X|
|Summary of errors by CPT section||X|
|Rationale for changes with specific coding guideline references||X||X|