What Elements Should Be on an Inpatient Coding Audit Checklist?

Medical coding audits can uncover billing mistakes and intentional fraud, potentially sparing healthcare organizations from incurring costly fines. But deciding on an inpatient coding audit checklist may prove to be challenging.

There are some basic components every healthcare organization should include in an inpatient coding audit, including:

Patient Information Verification
Patient verification is an integral component of healthcare facility’s billing and collections processes, helping ensure an efficient experience for both staff and patients alike. It involves verifying insurance coverage of each individual to provide accurate estimation of copayments, deductibles, preauthorization requirements, as well as to avoid billing errors while increasing patient satisfaction.

An individual patient identifier is defined as any information directly associated with an individual that reliably identifies him/her as the recipient of services or treatment. Acceptable examples are name, assigned identification number, date of birth or any other unique identifying details for that individual.

Facilities must develop policies and procedures to ensure physician documentation of coded diagnoses is included in health records. Communications tools like query forms, summary forms and attestation sheets should never be used as replacements for direct physician communication; this helps ensure accuracy is preserved while mitigating compliance risks as well as reducing duplicate entries which could become costly over time.

Documentation Accuracy
Conducting a medical coding audit is an excellent way to increase revenue, ensure compliance and detect coding errors. When choosing external audit companies, be sure to choose one with comprehensive services for ambulatory surgery center (ASC) code accuracy, physician group coding and facility documentation as well as clinical documentation.

Coding of Inpatient Evaluation and Management (E&M) can be more complex than outpatient E&M because the type of code selected depends on three key components: history, exam and medical decision making. For maximum reimbursement purposes, selecting accurate diagnoses is of utmost importance.

Education of your coding staff on the latest coding guidelines and conducting regular audits are also vitally important, helping them detect errors or deviations from coding guidelines before Medicare or private insurers do it on your behalf. For instance, documenting chronic renal insufficiency without actually diagnosing it could result in costly overpayments due to unnecessary submission of codes for it.

Coding Accuracy
Accurate coding is crucial to ensure accurate and timely reimbursements are received from managed care plans, consumer scorecards and comparison studies. Furthermore, accurate coding helps measure non-financial metrics like severity of illness and risk of mortality that are leveraged during negotiations, scorecards and comparison studies.

An effective coding audit program must cover all encounters, both inpatient and outpatient coding. This helps maximize revenue while assuring compliance, while uncovering issues that need improvement.

Audits should include more than just coder accuracy assessments; they must also assess DRG assignment accuracy for reimbursement, clinical decision support, quality reporting and worldwide comparative trending purposes. Analyzing DRGs as well as capture rates of CC and MCC codes helps identify opportunities for documentation improvement that will enhance coding accuracy.

By conducting accurate and comprehensive coding audits, health care facilities can identify and mitigate a range of operational and clinical challenges, from missed revenue to denied claims to unnecessary high costs. By employing a centralized coding audit tool that closely integrates with EHRs, billing systems, AHIMA codes and guidelines and their respective EHRs/billing systems/AHIMA guidelines health care facilities can achieve increased productivity, accuracy while simultaneously cutting costs.

Medical Necessity Substantiation
Medical coding audits should become part of your revenue cycle on an ongoing basis to ensure compliance and detect mistakes such as upcoding, unbundling, and miscoding which can result in extra payments or false claims.

As medical necessity criteria become more stringent, it is imperative that inpatient coding processes are thorough and accurate. This means reviewing correct use of modifiers, verifying all required ancillary services were coded accurately, and making sure all Medicare-required diagnoses exist.

Senior evaluators should fail this check if the enrollee’s name and identification information do not correspond with that on the Medical Record Coversheet (CMS-HCC), such as when using middle names or maiden names or providing Health Insurance Claim Numbers belonging to spouses of beneficiaries who appear on INV1. If INV1 fails, then evaluating INV3 case by case to decide if it passes or fails is recommended.