Medical Coding Audit – Sample Medical Coding Audit Checklist

Medical coding audits performed regularly can improve documentation accuracy, ensure coding compliance with quality benchmarks and reduce claims denials. Conducting such an audit with a random sample of documents is key for running an efficient healthcare organization.

Coding audits help detect errors such as improper documents, unbundling services and up-coding that lead to denials and decrease in clean claim ratio. Here is an example medical coding audit checklist for diagnostic and procedure coding.

1. Patient Information Verification
Medical coding audits should include patient information verification. This allows medical organizations to detect errors that could have serious repercussions for themselves, including discrepancies between patient identifiers or incorrect discharge/transfer to wrong family or reordering by someone other than themselves of medication and more.

Verifying that all services were provided and documented for every encounter is also part of this audit, with examination of documentation for each case as well as demanding correct CPT codes being assigned for reimbursements. A medical coding audit can help detect these errors as they can lead to revenue losses or denials; rectifying them and getting reimbursements should also be included as part of this process. Furthermore, audits should identify reasons behind past denials so as to prevent similar ones happening again.

2. Documentation Accuracy
Accurate documentation and coding is key to submitting clean claims and optimizing reimbursement. Medical coding audits can identify documentation errors that lead to denials and reduce your clean claims ratio.

Documentation errors include unbundling codes, failing to include modifiers and not selecting the highest level of specificity for codes and modifiers used, among other issues. An automated second-level review engine such as Empeek’s NLP-targeted epiFinalCheck can detect and address such problems before they cause claim denials or rejections.

At LexiCode, it’s also essential that medical coders follow the latest coding guidelines issued by agencies like International Classification of Diseases (ICD) and Current Procedural Terminology (CPT). A coding audit can uncover areas where this isn’t being done efficiently – we support any physician query process healthcare providers already have in place so they have all of the information they need for accurate coding.

3. Coding Accuracy
An incorrect medical coding practice leads to denials, leading to revenue losses. An accurate medical coding audit helps detect causes behind any discrepancies and protect your bottom line by eliminating inaccuracies that threaten its profitability.

Medical coding audits are an excellent way to pinpoint areas for improvement within healthcare organizations. From unbundling, inconsistent education or documentation issues to unbundled services or documentation issues, audits reveal areas that could benefit from additional support in terms of both training and support that would increase accuracy.

Additionally, it’s crucial that audit findings and compliance changes be communicated quickly to all billing team members, so coders can adapt their workflow quickly to improve coding accuracy. Engaging physicians as part of the coding process has proven particularly successful at increasing its precision; physicians document clinical encounters which then become claims for reimbursement.

4. Medical Necessity Substantiation
Medical coding audits increase the frequency and accuracy of error identification, correction, reduced revenue loss, and overall operational efficiency improvement. They can be conducted monthly, quarterly or annually.

An effective medical coding audit checklist must cover multiple areas, including verification of patient information, documentation accuracy, coding accuracy, and medical necessity substantiation. Such audits can be conducted either internally within healthcare organizations, independent practices or external companies.

Payer audits can be daunting for healthcare organizations as they pose an existential threat to financial health. But the key to successfully handling payer audits lies in taking proactive steps in order to avoid them in the first place, such as conducting regular coding and documentation audits – along with clearly outlining an audit process with its benefits clearly communicated to team members.

5. Compliance
Medical coding accuracy is vital to healthcare organizations’ profitability and patient records integrity. Conducting regular coding audits allows healthcare organizations to detect current coding issues as well as gain knowledge that helps streamline procedures and develop policies more efficiently. Over-coding or under-coding services provided to patients is inaccurately represented in patient records.

Healthcare organizations should use benchmark data from medical associations, commercial vendors and Medicare’s Comprehensive Error Rate Testing (CERT) reports as benchmarks when setting targets for their coding audits.

Periodic reviews of coding compliance, whether conducted internally or by an outside audit firm, are an integral component of financial health for healthcare systems and providers. Not only will this reduce compliance risk but it will allow hospitals and providers to detect errors more frequently as well as recapture lost revenue to ensure greater success with financial performance.