By Mike Evans, RHIA, CCS, vice president of coding and compliance at In Record Time, Inc.
Internal coding audits have always been important. However, as third-party auditors continue to scrutinize documentation and coding practices, it’s more important than ever to ensure that these audits occur regularly and that they’re effective. All too often, internal auditors overlook critical aspects of the audit, resulting in skewed data that may not paint a clear picture of trends and patterns. Even when conducted properly, audits may not yield results that are truly useful to the organization.
Following are some of the most common mistakes that internal coding managers and/or HIM directors make when conducting internal coding audits.
1. Audits are too narrow. Internal managers sometimes approach an audit with an agenda to increase CC or MCC capture. When organizations narrow their focus in this way, they may miss out on other problems within the documentation or coding. Instead, organizations should focus audits on documentation integrity—not simply identifying missing elements that would have increased reimbursement. Ideally, audits should ensure the following:
· Multiple CC and MCC capture, when appropriate. Capturing only one single CC or MCC may not be sufficient in terms of ensuring a correct severity of illness (SOI) or risk of mortality (ROM). SOI and ROM both affect the observed vs. expected death rate—an important indicator of the quality of care provided.
· Correct POA indicator assignment. This plays an important role in patient safety indicator (PSI) scores. An inflated POA indicator rate could inflate the PSI rate as well.
· Compliant complication reporting. Physicians are hesitant to label complications as such; however, organizations need to encourage physicians to document complications when they occur. Reiterate to physicians that complications that occur intra-operatively are generally not the fault of the physician, but rather they’re due to a problem with the patient’s own health circumstances.
2. Audits don’t look beyond the organization’s own walls. One of the biggest mistakes that organizations make is not looking at how their data compares with other facilities in the state, region, or nationwide. Knowing how your organization compares with its peers is important because patients have access to this data that is reported on an aggregate level to various state health agencies. Sites such as Physician Compare and Hospital Compare make it very easy for consumers to shop around for the best quality care. Organizations need to know how they stack up against other facilities so they can take steps to improve data quality and public perception.
Knowing how the organization compares with others is also important in terms of gauging vulnerability for external audits. The Program for Evaluating Payment Patterns Electronic Report (PEPPER) is a helpful resource that provides hospital-specific data statistics for improper payment targets. Organizations can use PEPPER to compare their data other hospitals or facilities in the state, specific Medicare Administrative Contractor (MAC) jurisdiction and the nation.
3. Auditors don’t look for the story behind the numbers. Internal auditors may not look for the root cause of audit results. Instead, they must simply assume that the results are based on incorrect coding. However, the trigger may be something process-related and/or entirely unrelated to coding. For example, if the organization’s procedure is to require coders to code without the discharge summary, this might affect a coder’s ability to capture the principal diagnosis correctly. Consider a transient ischemic attack (TIA). When a physician documents both a TIA and a cardiovascular accident (CVA) throughout the record—but doesn’t rule out the CVA until the discharge summary—how can the coder truly know what proper principal diagnosis to report?
Another example relates to septicemia vs. urinary tract infection (UTI). Are coders required to query when the record is unclear? Are they given sufficient time to do so? If not, unclear documentation could lead to an unusually high rate of septicemia that could appear quite alarming during an audit.
Other root causes could relate to insufficient physician documentation, EHR glitches, etc.
4. Auditors don’t use updated resources. It’s a full-time job to keep up with ever-changing audit targets and requirements. However, using outdated resources and references can provide skewed audit results. Be sure to use updated coding guidelines and updated insurer policies. The Recovery Auditor FY2013 Report to Congress and FY 2015 OIG Work Plan are also good references in terms of structuring an audit and keeping updated on the latest targets.
5. No follow-up education is provided. After the conclusion of an internal audit, provide audit results to coders, physician advisors, and CDI specialists. Include a physician advisor when providing education to physicians, as they generally respond more positively when receiving information from a peer.
6. Organizations don’t perform follow-up audits. Perform an audit six months after concluding the original audit. This ensures the efficacy of any steps taken to rectify problems identified during the first audit.
How an external vendor can help
External coding vendors provide an unbiased look at an organization’s data. These auditors don’t have an agenda, and they also have no connection to the data. They often provide the impartial analysis that organizations need.
In addition, external vendors can perform the type of in-depth data analysis necessary to compare an organization’s performance (i.e., its DRG and APC mix) with similar facilities on a city, state, regional, or national level. Many external auditors work with clients nationwide, meaning they bring a wealth of knowledge and experience to the table. Organizations benefit from this bird’s-eye view of what’s going on in the industry in terms of third-party auditor trends.