Introduction
A coding audit is the process of official examination and validation of the medical record documentation and coding that is conducted regularly. It is necessary for ensuring compliance of the system with established standards and is considered to be a good quality assurance activity intended to improve accuracy. A coding audit plan is a set of milestones that are to be implemented before, during, and after the audit. It consists of the steps outlined below that comprise the complete process of auditing.
Identification of ones responsible for coding audit conducting that can be external or internal staff. Development of the scope of the coding audit, which includes its setting, such as inpatient, outpatient, or physician office, and determination of an audit size expressed in the volume of records. Per OIG recommendations, five to ten random charts per physician and up to 20 charts per audited time is the appropriate size (Bryant, 2020).
It is also possible to use the rule of thumb for the percentage of charts that indicates the necessity to review 10% of the eligible charts. At this stage, the frequency of audits or time frame is also determined and can be quarterly, monthly, or other. A coding variance or error should also be determined, the proposed value for which is usually 95% (Bryant, 2020). In the third stage, auditing resources and tools should be determined. The instances are codebooks, OIG work plan, ICD-10-CM/PCS guidance, and others.
Then, an auditing function that is chart review is performed while documenting findings on an audit worksheet for further explanation and justification. In the next step, an audit summary is created that includes patterns, trends, recommendations, and the date of the next coding audit planned. It also should include a verbal presentation of findings and a narrative report. Coding staff should be provided time for generating input and response to the audit. The purpose of a coding audit is to improve the coding process. Therefore, corrective action and resolution of variances should be implemented along with defining systemic patterns or trends for future consideration and the following audits. Finally, the employees concerned, such as CDI staff and physicians, should be educated and supported based on the results of the audit.
The Use of Office of Inspector General Work Plan
The Office of Inspectors Genera’s (OIG) work plan is intended to set projects such as audits and evaluations during the fiscal year. It presents processes conducted by the Board of Governors of the Federal Reserve System and the Bureau of Consumer Financial Protection (Work Plan, n.d.). Web-based work plan issued quarterly, ensuring that it is aligned with the work planning process. Newly initiated items are added, based on mandatory requirements for OIG reviews, such as laws and regulations.
There are three categories for projects: initiated which implies that a project is expected to be completed, in development, which means a determination of a project’s scope, and planned which indicates that the project is identified (Work Plan, n.d.). It is necessary to review the work plan regularly to ensure compliance with the latest standards, as projects can be added, updated, canceled, or terminated at any time.
The use of the OIG work plan is explained by the need for quality assurance specialists to be familiar with the federal; government’s perspective as they determine how the auditing process is to be conducted. The work plan also outlines expectations for upcoming management and performance challenges. It implies that this resource is important as a referential one for healthcare compliance programs. The other resources that should be implemented during coding audit plan preparations are the coding Clinic, the ICD-10-CM/PCS Official Guidelines for Coding and Reporting, AMA’s CPT Assistant, and many others (Medicare Web, 2018).
They provide an insight into updated code conditions and procedures. Without familiarising with such resources, an auditor can’t identify the core issues and mistakes made by coders. Therefore, a work plan and other resources are to be utilized while preparing an auditing plan for compliance with the latest standards and best practices.
Policies and Procedures to Monitor Abuse or Fraudulent Trends
It is possible to determine the phenomena of abuse and fraudulent trend and explain how it is related to an audit. Medical fraud is referred to as tendencies to submit false claims, receive or pay remuneration, and make prohibited referrals. For instance, ordering medically unnecessary items for patients is a fraud (Medicare Learning Network, 2021). Simultaneously, Medicare abuse describes practices that result in unnecessary costs to Medicare programs and does not meet professionally recognized standards of care. There are the following sets of policies and rules to prevent abuse and fraud and be considered during audit plan development and implementation. False Claims Act, Anti-Kickback Statute, Physician Self0Referral Law, Social Security Act, and the United States Criminal Code are the federal laws utilized while ensure accurate coding and billing (Medicare Learning Network, 2021, p. 8). Consideration of these laws is a key to fraud and abuse prevention.
In addition, the following contractor efforts are intended to prevent adverse trends: Recovery Audit Program, Comprehensive Error Rate Testing, Unified Program Integrity, Medicare Drug Integrity, and others (Medicare Learning Network, 2021, p. 18). The control of documentation done by auditors is a necessary part of verifying compliance with those requirements. In the above-mentioned coding audit plan, the necessity to educate healthcare staff is outlined. It is a part of the auditing to train personnel about the law and policies.
Interrelationships Between the Providers and Payers in Audits
In audits, payers are the ones who set service rates, collect payments, and process and pay provider claims, while providers are the ones offering services, like clinics. During audits, it is necessary to verify that claims submitted have the required supporting documentation, such as invoices, records, and others. The absence of them may be an indicator of intentional fraud or abuse or an unintentional mistake.
Providers are audited to ensure that there are no overpayments and decrease the number of inappropriate Medicaid claims paid. The reason to examine a provider is to detect inadequate documentation, upcoding, inappropriate billing, coinsurance, deductibles, and other issues that must be addressed (Medicare Learning Network, 2021). For this purpose, different forms of audits are conducted, such as pre or post-payment ones. They enable to examine every stage of the prose of healthcare providing to prevent cases of fraud and abuse. Therefore, payers and providers have interrelationships based on the provision of paid medical services, which is a reason for fraud or abuse and should be prevented by auditing.
References
Bryant, G. (2020). Coding Audits: A Compliance Necessity. ICD10Monitor. Web.
Medicare Learning Network (2021). Medicare Fraud & Abuse: Prevent, Detect, Report. CMS. Web.
Medicare Web (2018). Q&A: First steps in preparing for a coding audit. RevenueCycleAdvisor. Web.
Work Plan. (n.d.). Web.