Types of Medical Coding Audits

Medical coding audits ensure the accuracy, completeness, and compliance of coding procedures in a healthcare setting. They play a vital role in protecting against fraudulent practices and in maintaining the integrity of healthcare data. There are several types of medical coding audits, and they generally fall under two umbrellas – compliance audits and focused audits.

In the past few years, HIA has seen a steady increase in focused audits:

Our Most Sought-After Focused Audits Include:

Onboarding and Education Audits

• What it is: This type of audit ensures that new coders or those transitioning into new roles are accurately trained and adhering to established coding guidelines. It focuses on the proper understanding and application of coding rules and documentation practices.
• Why it matters: Proper onboarding and continuous education of coders reduces errors, ensures compliance, and boosts overall coding quality. These audits aim to identify any gaps in understanding that might lead to inaccurate or non-compliant coding, which could impact reimbursement rates and result in costly audits later.

Mortality Audits

• What it is: Mortality audits focus on ensuring that the coding for patients who have passed away is accurate and reflective of the care provided. This includes reviewing diagnoses, procedures, and any related factors to confirm correct coding.
• Why it matters: Correct mortality coding is essential for accurate data reporting, influencing public health statistics, and ensuring proper reimbursement. These audits help identify areas where mortality cases might be misclassified, which could lead to incorrect data reporting or missed revenue.

Quality Measures Audits

• What it is: These audits ensure that the coding process accurately reflects quality measures that are used to assess the effectiveness and efficiency of healthcare services. This includes checking that coding practices align with specific quality metrics or national guidelines that affect payment or reimbursement. Why it matters: Accurate quality measure coding ensures that healthcare organizations meet regulatory requirements and performance standards. These audits help identify coding discrepancies that could affect performance scores and ultimately, reimbursement rates tied to these measures.

Clinical Documentation Improvement (CDI) Audits

• What it is: CDI audits focus on evaluating the quality and completeness of clinical documentation to ensure it accurately supports the coding process. This includes verifying that diagnoses and procedures are clearly documented, substantiated by clinical evidence, and in compliance with coding rules.
• Why it matters: Strong documentation directly impacts coding accuracy and the overall integrity of patient records. CDI audits identify areas where documentation may be lacking or unclear, helping to improve the accuracy of coding and minimize audit risks while supporting accurate reimbursement.

Denial Audits

• What it is: Denial audits review claims that have been rejected by payers, identifying the root cause of denials and providing insights into potential coding errors or documentation issues that led to the rejection. This audit helps healthcare organizations address these issues proactively.
• Why it matters: Denial audits help organizations understand the reasons behind claim rejections and how to prevent them in the future. By identifying the underlying issues, these audits allow healthcare providers to improve their coding practices, appeal denials more effectively, and reduce revenue loss from denied claims.

Revenue Integrity Audits

• What it is: Revenue integrity audits focus on ensuring that all revenue-generating services are properly coded and documented, preventing underbilling or overbilling. This audit checks that all services provided to patients are accounted for accurately in the coding system.
• Why it matters: Ensuring that services are correctly coded and billed is crucial to maintaining financial health and avoiding compliance issues. Revenue integrity audits help identify areas where revenue may be missed due to coding errors or omissions, ensuring that healthcare organizations are receiving the correct reimbursements.

Service-Specific Audits

• What it is: Service-specific audits focus on particular specialties or high-volume service areas, such as cardiology, orthopedics, or surgery. These audits examine the coding practices within a specific service line to ensure compliance with specialty-specific guidelines and accuracy.
• Why it matters: Certain specialties may have more complex coding requirements, and these audits help ensure that coders are correctly applying the right codes for specialized services. Service-specific audits help mitigate errors that could lead to undercoding, overcoding, or improper reimbursements.

Compliance Audits: An Essential Role in Healthcare Organizations

While focused audits have gained prominence, compliance audits still play a crucial role in ensuring overall adherence to regulatory requirements and best practices. These audits are typically broader in scope and aim to evaluate the effectiveness of the entire coding process in meeting legal and industry standards. Compliance audits assess overall coding accuracy and documentation quality across a range of departments or services to ensure that they meet the standards set by CMS, the OIG, and other governing bodies.

Both types of audits—focused and compliance—serve complementary roles in healthcare organizations. Compliance audits provide an overarching evaluation, while focused audits allow for a deep dive into specific areas where issues might arise. Together, these audits work to ensure that coding is accurate, documentation is thorough, and regulatory standards are met.

Why the Shift Toward Focused Audits?

The increasing emphasis on accurate reimbursement, cost efficiency, specificity, and the maturation of compliance programs has led to a rise in focused audits. Many healthcare organizations now leverage advanced data analytics tools and technologies to identify patterns, outliers, and potential coding discrepancies within large datasets. Focused medical coding audits use these tools to analyze claims data, coding patterns, and other relevant information, allowing organizations to more effectively address specific areas of concern.

In conclusion, whether conducting a focused audit to target a high-risk area or a comprehensive compliance audit to ensure overall adherence to coding standards, the goal is the same: to enhance the quality of healthcare documentation and coding, prevent errors, and ensure that reimbursement is accurate and timely. These audits are an essential part of maintaining compliance, improving operational efficiency, and ultimately improving the financial health of healthcare organizations.

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.