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Coding Audit: What Is It?

Audits are an important aspect of any healthcare practice.  The OIG requires healthcare providers to perform yearly compliance audits.  One aspect of an audit is to evaluate coding against documentation. 

 

When providers request coding audits from us, we follow the general guidelines below.  All audits are unique and a fact finding mission.  Each requires fluidity, as audits can unearth unknowns, and following those unknowns can change the course of any audit.

Step 1

Define the scope of the audit.  What is the purpose of the audit? 

  • General coding audit

  • Yearly compliance audit

  • General process improvement

Step 2

Determine charts to review. 

OIG recommends 10-15 charts per provider.

Step 3

When performing an audit, we follow an internal three step process. 

  1. Each note in the chart is treated as new coding.  The note is coded by a CPC, without knowledge of the original codes used.

  2. The notes and new codes go a second CPC to review and evaluate against the original codes used.

  3. Lastly, the CPCs meet with the manager of the audit to discuss coding choices, against original codes billed and perform final computerized scrubbing.

Step 4

After the data is analyzed and our findings are summarized on an Audit Worksheet, we present the provider with our findings.  Meetings are offered with provider and provider staff.