5 Reasons Why Every Practice Needs Medical Coding and Auditing

Partnering with a quality coding consulting company and conducting frequent audits ensures:

1. Compliance with Healthcare Regulations: Regular auditing helps identify any coding errors, discrepancies, or potential compliance issues, allowing them to be addressed promptly.

2. Revenue Optimization: Frequent auditing helps identify areas for improvement, optimize coding practices, and maximize revenue generation.

3. Improved Patient Care: Accurate coding and auditing contribute to better patient outcomes by providing reliable data for research, quality improvement initiatives, and clinical decision-making.

4. Enhanced Operational Efficiency: By implementing standardized coding practices and conducting routine audits, practices can identify areas of inefficiency, reduce coding errors, and streamline the claims submission and reimbursement process.

5. Risk Mitigation and Fraud Prevention: Consistent auditing helps identify any instances of incorrect coding, upcoding, or unbundling of services, which can lead to compliance issues or fraudulent billing practices.

Here’s some frequently asked questions we get when it comes to medical coding and audits:

Why do I need a medical coding audit?

For starters, the government strongly recommends that any practice collecting reimbursement undergoes routine medical coding audits. It’s one of those things that’s ‘just good business’. Audits serve as a preventative measure to catch potential compliance errors – errors that could really impact your bottom line, reputation and, most importantly, the level of care you deliver to your patients. Audits help to mitigate compliance risks, ensure appropriate reimbursement, identify educational opportunities for coders,and Providers. Another value add? It helps you to accurately reflect the acuity level and needs of your patient population.

What are the different types of coding audits?

There are a few types of medical coding audits we perform on a routine basis: pre-bill reviews, retro reviews, random sample, targeted, profee, Evaluation and Management (E&M), surgical CPT, new coder reviews, mortality reviews, new provider reviews, & investigatory reviews.

What does a Professional Fee Auditor do?

In short, a lot. Here’s a breakdown of what Profee Auditors do on a day-to-day, or week-to-week, basis:

• Perform compliance audits based on current CMS, CPT, ICD-10 guidelines and state and federal regulations
• Utilize the CMS 95/97 or 2023 guidelines depending on place of service and date of service and documentation guidelines for E&M reviews
• Review encounters assigned to ensure appropriate diagnosis, and E&M/CPT reporting, documentation opportunities and compliance issues
• List findings with recommendations from guidelines/regulations (CMS Documentation Guidelines, Coding Clinic, Federal Regulations, CMS Physician Services Guidelines, etc.) to provide clients with educational feedback for corrective action. (Psss - Much of this coding education is now publicly available on our new online coding platform, HIAlearn)
• Complete client rebuttals and make appropriate changes
• Run preliminary and final reports and conduct summation conferences with administration, coding staff, and providers as requested

How do you select a medical coding company to perform your audit?

When selecting an external auditing company to perform your medical coding audit, you should keep in mind your overall audit objective and ask yourself the following:

• Does the company provide a review that meets your audit parameters?
• Do they schedule a review prep call and have consistent communication throughout the audit?
• Do they offer an audit exit call to discuss any review findings with you and your team in a clear and educational manner?
• What type of reports are provided to you after the review?
• Does the company provide any continuing coder or provider education?
• Do they have a rebuttal process in place?

About HIA Profee Services – HIApro

If you’re looking for assistance, HIA offers professional fee consulting services and coding support to provider groups. HIA's credentialed coders are up-to-date on all E/M and CPT coding guidelines. Our consulting service identifies specific areas of financial and compliance risk, provides pertinent information and educates clients on proper documentation, billing and coding practices.

Provider Groups partner with us for:

• PRN and Outsourced Coding Support for Professional Fee Records
• Provider Coding and Documentation Reviews
• Coding Education
• Atom Audit, our Professional Fee Medical Coding Audit Tool

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