Top 5 Outpatient Coding Metrics to Pay Attention to During Medical Coding Audits

Medical coding audits are essential for maintaining precise and compliant coding practices in outpatient healthcare settings. Keeping a close eye on key metrics during these audits allows for the identification of areas for improvement, and helps evaluate the overall quality of coding procedures in the outpatient environment. This process can also serve as a valuable tool for providing positive feedback and validation to your outpatient coding staff. Here are the top five metrics you should focus on during your medical coding audits in outpatient settings:

APC Accuracy

• APC (Ambulatory Payment Classification) accuracy is critical as it directly impacts the payment to the facility. It is essential to closely examine the Total APC accuracy rate to assess the facility’s financial risk due to overreporting or underreporting. During your audit, analyze the APC assignments and compare them to the medical documentation. Identify if any of the APC changes were influenced by missing documentation and note these as query opportunities for the medical staff.

ICD-10-CM Accuracy

• In the outpatient setting, ICD-10-CM accuracy is paramount due to medical necessity requirements. A missing or incorrect diagnosis code could lead to a denial for a test or procedure, impacting revenue. Ensure that the codes are in accordance with the patient’s medical record and that all relevant diagnoses are coded to the highest level of specificity.

CPT Accuracy

• CPT (Current Procedural Terminology) accuracy is essential because it drives your APC assignments. The CPT accuracy might differ from your APC accuracy due to the bundling of several CPT codes into one APC. Verify that coders are following official guidelines, using CPT assistant, and adhering to NCCI (National Correct Coding Initiative) edits.

Modifier Accuracy

• Reviewing modifier accuracy is vital as it can have significant financial implications for both the facility and the patient. For example, misuse of Modifier PT or 33 can affect the patient’s financial obligations, while Modifier 50 could impact the facility’s reimbursement. During audits, ensure that modifiers are being used appropriately and according to the latest guidelines.

Chargemaster/Charge Capture Assigned Codes

• Many facilities have codes assigned by the chargemaster or a charge capture employee. It is essential to review some of the codes, like Interventional Radiology, Injection and Infusion, Observation Hours, and Facility E&M, that can be assigned by HIM (Health Information Management) but are captured through other means. Conduct a thorough review to ensure these codes are being assigned correctly and that they align with the services documented in the patient’s medical record.

Conducting regular and thorough medical coding audits with a focus on these key metrics is essential for maintaining compliance and ensuring accurate reimbursement for services. Investing in ongoing education for coding staff and fostering open communication between coders and medical staff can significantly improve coding accuracy and minimize financial risk for healthcare facilities.

Since 1992, HIA has been the leading provider of compliance audits, coding support services and clinical documentation audit services for hospitals, ambulatory surgery centers, physician groups and other healthcare entities. HIA offers PRN support as well as total outsource support.

The information contained in this coding advice is valid at the time of posting. Viewers are encouraged to research subsequent official guidance in the areas associated with the topic as they can change rapidly.