What to Consider Before Your Next Coding Audit
From audit type to budget, here’s what to consider before your next medical coding review
A medical coding audit is a process that includes internal or external reviews of medical coding and billing accuracy, procedures or policies in place, and any other component that affects the medical record documentation. Medical coding audits are a preventative measure to catch potential compliance errors that could result in liabilities or investigations. These compliance related issues can also impact your bottom line, your organization’s reputation, and most importantly, the level of care you deliver to your patients.
Retrospective or Prebill Audit & Sample Methodology
Coding audits can be retrospective, a review of the submitted claims, or prospective, an analysis of coding prior to billing. Prebill audits can also impact other areas like quality measures and compliance scores as errors are corrected prior to final billing. On the other hand, these audits can raise your unbilled as more time is needed to review and finalize records. Retrospective reviews can allow you to focus on specific DRG’s, codes or procedures over a longer time frame to get an accurate picture if there is a potential area of concern. Both types of reviews have their advantages and HIA can help customize a plan to fit your organization’s compliance needs.
Once you have selected the type of audit, the next step is to determine sample selection methodology. Some organizations decide to select a random sampling of all their records from a specified period of time, while others will pull a random sampling from a targeted list: i.e., a new coder prebill review. We recommend clients perform a variety of coding audit methodologies in order to gain a better understanding of any compliance related issues. If you are using an external audit company to perform the reviews, they will usually select the records for you based on the parameters you set in place for the audit or through random sampling.
It is important to keep the objective of the audit top of mind when planning your next coding audit. At HIA, we believe in customizing a review to meet the client’s needs and the goal of the overall audit. For example, if the client is looking to determine if coding is adversely impacting CMI, we would look at a focused sample of records, likely DRGs with no CCs/MCCs. That same recommendation would not necessarily be made if the client is looking to determine how their coding staff is performing. In that case, we would likely recommend a standard interval coding quality audit, random sample, that would be more representative of the coding performed on a day-to-day basis. Budget is also a main factor to consider in an audit. If the client has multiple objectives, but they do not have the funds allocated to meet all of those objectives at once, we can help determine how to get the best bang for their buck, while establishing a timeline to meet all of their needs.
Accuracy & Productivity
Accuracy and productivity are both immensely important in the overall auditing process. Coding accuracy can be indicated by performing regular coding audits, while coding productivity is more of an operational/management indicator. However, your rockstar coders will be able to maintain both a high coding accuracy and productivity. It is important to determine where your coding staff’s strengths and weaknesses lie in order to manage your department effectively.
Coding audits can seem costly at first, but the benefits far outweigh the risks a facility may discover when coding hasn’t been regularly reviewed. A coding audit can identify potential at-risk dollars, i.e., overpayments and underpayments. Medicare defines an overpayment as any payment that exceeds amounts properly payable under Medicare statutes and regulations. When Medicare identifies an overpayment, the amount becomes a debt you owe the Federal government and Federal law requires CMS to recover all identified overpayments. Medicare overpayments commonly occur due to:
- Incorrect coding
- Insufficient documentation
- Medical necessity errors
- Processing and other administrative errors
Overpayments must be returned within 60 days from the date the overpayment was “identified,” or by the date any corresponding cost report was due, whichever is later. Failure to return an overpayment has severe consequences.
The best way to maintain compliance is to schedule frequent external coding audits. Two eyes are better than one. Routine coding audits can help you uncover any underlying issues and allow you time to put corrective action in place, so the issue doesn’t continue (and you won’t be forced to pay back the government!). The cost of a well-executed coding audit is well worth it in the long run.
Selecting an external auditing company
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?
HIA offers both preliminary and final reports. Recommendation worksheets will be posted to our secure client portal each day throughout the engagement and preliminary statistical reports will be made available immediately upon conclusion of the chart review. Final narrative reports, including both a Report of Findings and an Executive Summary, will be available after an educational exit conference call. HIA has over 120 Action Plans available for both your coding and physician staff that are available for Continuing Education Credits.
Partnering with an experienced coding consulting company, like Health Information Associates, can produce measurable improvements. Better documentation and coding lead to better data, information and insight into patient care issues that, ultimately, leads to better patient care.
CMS released the IPPS proposed rule on 4/27/21 outlining the proposed changes to the Inpatient Prospective Payment System for FY2022, which begins October 1, 2021. Later this year, sometime in August, CMS will release the Final Rule. Currently CMS is reviewing responses to their proposed rule and will address them in the final rule.
Anticoagulants and antiplatelets are used for the prevention and treatment of blood clots that occur in blood vessels. Oftentimes, anticoagulants and antiplatelets are referred to as “blood thinners,” but they don’t actually thin the blood at all. These drugs slow down the body’s process of making clots. Their main function is to keep the patient’s blood from clotting or turning into solid clumps of cells. These drugs do this by interfering with either fibrin or platelets in the blood.
Carotid artery disease is a vague category that can incorporate many different carotid artery issues. Some physicians may feel that they are being clear the patient has plaque, stenosis, or occlusion of the artery, but in ICD-10-CM the specificity must be included in the documentation.
10 ICD-10 Codes for Superheroes. Superman: T78.2XXA Anaphylactic reaction; substance: kryptonite. Batman: F44.81 Dissociative identity disorder. Robin: F60.7 dependent personality. The Hulk: L30.4 Erythema intertrigo. Wonder Woman: T24.032A Burn of unspecified degree of left lower leg. Black Panther S93.401A Sprain…
Practices have not seen many revisions to the Evaluation and Management (E/M) office / outpatient visit guidelines in three decades – until now. As of January 1, there are new E/M coding guidelines. We’ll get to those in a bit, but first let’s look at why they changed.
Pseudoseizures are a form of non-epileptic seizure. These are difficult to diagnose and oftentimes extremely difficult for the patient to comprehend. The term “pseudoseizures” is an older term that is still used today to describe psychogenic nonepileptic seizures (PNES).
With the implementation of ICD-10-CM came different codes and coding rules for many diagnoses. One of these is the coding of bowel obstruction when the patient presents for this condition that is caused by another condition.
This is Part 5 of a five part series on the new 2021 CPT codes. For the remaining areas we will just briefly summarize the section. Due to the intricate nature of these sections in CPT, it is recommended that the coder read the entire section notes associated with the new codes.
This is Part 4 of a five part series on the new 2021 CPT codes. In this series we will explore the CPT changes in the urinary, nervous, ocular and auditory systems. There are 2 new urinary/male reproductive system codes with no revisions or deletions; 3 new female reproductive codes with 2 deletions, 0 new with 4 deleted nervous system codes with 5 revisions; 5 new eye category III codes; and finally a 2 new auditory codes with one deletion.
This is Part 3 of a five part series on the new 2021 CPT codes. In this series we will explore the cardiovascular system CPT changes. There are 5 new cardiovascular CPT codes added with 0 deletions and 4 revisions.
This is Part 2 of a five part series on the new 2021 CPT codes. In this series we will explore the CPT changes for FY2021 and include some examples to help the coder understand the new codes. There are 0 new musculoskeletal CPT codes added with 0 deletions and 2 major revisions along with an extensive update to arthroscopic loose body removal requirements. For the respiratory system, there were 2 new codes, one code deletion and no revisions.
This is Part 1 of a five part series on the new 2021 CPT codes. In this series we will explore the CPT changes for FY2021 and include examples to help the coder understand the new codes. For 2021 in general, there were 199 new CPT codes added, 54 deleted and 69 revised.
In January, new CPT codes were released. There were 248 new CPT codes added, 71 deleted and 75 revised. Most of the surgery section changes were in the musculoskeletal and cardiovascular subsections. These included procedures such as skin grafting, breast biopsies, deep drug delivery systems, tricuspid valve repairs, aortic grafts and repair of iliac artery.
We have seen many updates and changes to COVID-19 (SARS-CoV-2) since the pandemic started. On January 1, 2021 we will see even more changes as outlined in this post. Also the CMS MS-DRG grouper will be updated to version 38.1 to accommodate the changes.
In the previous three parts of this four-part series, we discussed the new ICD-10-CM diagnosis code changes, ICD-10-PCS procedure code changes and FY2021 IPPS changes. In this last Part 4 of the series, we will review the NTAP procedure codes and reimbursement add-on payments for FY2021.
In the previous two parts of this four part series, we discussed the new ICD-10-CM diagnosis code changes and ICD-10-PC procedure code changes. In this session we will review the major IPPS changes for FY2021.
This is Part 2 of a 4 part series on the FY2021 ICD-10 Code and IPPS changes. In this part, the ICD-10-PCS procedure codes are presented. For FY2021 ICD-10-PCS there are 78,115 total codes (FY2020 total was 77,571); 556 new codes (734 new last year in FY2020)…
This is Part 1 of a 4 part series on the FY2021 changes to ICD-10 and the IPPS. In this part, we discuss some of the new ICD-10-CM diagnosis changes. Here is the breakdown: 72,616 total ICD-10-CM codes for FY2021; 490 new codes (2020 had 273 new codes); 58 deleted codes (2020 had 21 deleted codes); 47 revised codes (2020 had 30 revised codes)
Acute pulmonary edema is the rapid accumulation of fluid within the tissue and space around the air sacs of the lung (lung interstitium). When this fluid collects in the air sacs in the lungs it is difficult to breathe. Acute pulmonary edema occurs suddenly and is life threatening.
“Client S” is a small, not-for-profit, 40 bed micro-hospital in the Southeast. HIA performed a 65-record review this year for Client S and found an opportunity with 15 of them. 9 had an increased reimbursement with a total of $43,228 found.
The coma scale codes (R40.2-) can be used in conjunction with traumatic brain injury codes, acute cerebrovascular disease or sequelae of cerebrovascular disease codes. These codes are primarily for use by trauma registries, but they may be used in any setting where this information is collected. The coma scale may also be used to assess the status of the central nervous system for other non-trauma conditions, such as monitoring patients in the intensive care unit regardless of medical condition.
In the past, there had been an Excludes1 note at I46.- Cardiac arrest that excluded R57.0, Cardiac shock. HIA had also received a letter from AHA on a case in the past that had stated that only I46.- Cardiac arrest would be coded if both were documented. In addition, the Third Quarter Coding Clinic page 26 had a similar case that asked if both could be coded, and AHA had instructed that only I46.9, cardiac arrest, cause unspecified would be coded if both were documented and that the CDC would be looking at possible revision to the Excludes1 note.
A higher CMI corresponds to increased consumption of resources and increased cost of patient care, resulting in increased reimbursement to the facility from government and private payers, like CMS. We know that documentation directly impacts coding.
Assign code Z20.828, “Contact with and (suspected) exposure to other viral communicable diseases” for all patients who are tested for COVID-19 and the results are negative, regardless of symptoms, no symptoms, exposure or not as we are in a pandemic.
The Centers for Medicare & Medicaid Services (CMS) announced new procedure codes for treatments of COVID-19 – effective as of August 1, 2020. Among the new codes are Section X New Technology codes for the introduction or infusion of therapeutics including Remdesivir, Sarilumab, Tocilizumab, transfusion of convalescent plasma, as well as introduction of any other or new therapeutic substances for the treatment of COVID-19.
One common element in many value-based programs is risk adjustment using Hierarchical Condition Categories (HCCs) to create a Risk Adjustment Factor (RAF) score. This method ranks diagnoses into categories that represent conditions with similar cost patterns.
Why are so many AKI records being denied? It’s hard to give one answer for why so many AKI records are being denied lately, but most appear to be due to the multiple sets of criteria available for use in determining if a patient has AKI, as well as physician documentation. As stated in Part 3 of this series, there are three main criteria/classifications used to diagnose AKI.
In previous parts of this series we looked at the definitions of AKI/ARF, causes, coding and sequencing, and the common clinical indicators that patients present with that are diagnosed with this condition. In Part 4, we will look at the documentation that should be present to report the diagnosis without fear of denial, as well as when a query is needed to clarify the diagnosis.
If the facility does a COVID-19 test, and test is negative, do I need a diagnosis code. The answer is yes, you will report a Z-code. The Z-code depends on the record documentation and circumstances of testing. For any patient receiving a COVID-19 test, if negative, there MUST e a Z-code to describe why the test was taken. (Test negative for COVID-19 and MD does not override negative results).