Health Information Management

Consider internal auditing options

HIM-HIPAA Insider, April 6, 2010

Want to receive articles like this one in your inbox? Subscribe to HIM-HIPAA Insider!

Coding managers often conduct internal audits, but other alternatives exist. Some organizations hire an individual who reports to the coding manager and who is responsible for conducting audits and providing education for the coding team. Rotating coding audit responsibility among senior coders is another option. Regardless of the approach, the individual must be competent and have the respect of team members.

Individuals who conduct quality reviews must be cognizant of anything that negatively affects the coding effort. Potential influences include:
  • Incomplete or nonspecific documentation from physicians
  • Incomplete infusion notes from nurses
  • Inefficient form design that creates opportunities for poor data entry
  • Untimely documentation needed to completely code records
All these situations affect coding quality and reimbursement, and they may signal a need for an action plan that requires the involvement of other departments or committees. Internal audits do not eliminate the need for periodic external reviews. HCPro’s 2009 coding productivity survey revealed that most respondents, including community hospitals, clinics, critical access hospitals, ambulatory surgery centers, pediatric hospitals, and rehabilitation facilities, undergo annual external coding quality reviews. Many of the teaching facility respondents indicated they undergo quarterly reviews.
 
Editor’s note: This article was excerpted from the new HCPro book, "The Coding Manager's Handbook," by Rose T. Dunn, RHIA, MBA, CPA, FACHE, FHFMA. Visit HCMarketplace.com for more information or to purchase a copy.



Want to receive articles like this one in your inbox? Subscribe to HIM-HIPAA Insider!

    Coding and You

  • Coding and You

    Coding and You is written specifically to help non-coders; medical assistants, lab technicians, compliance professionals...

  • Coder Productivity in Today’s Environment

    Insufficient staffing and lack of resources continue to plague HIM departments while they also cope with a move to...

  • Top ICD-9-CM Trouble Spots

    During this 2-hour audio conference, our speakers address eight common, complex conditions and diagnoses and give you best...

  • Coding Manager Orientation Kit

    Get the know-how to manage a first-class coding department Whether you are new to the role of Coding Manager, transitioning...

  • Facility E/M Coding: Tune up your criteria

    During this live two hour audioconference, speakers will explain how to tune-up facility assessment criteria and ensure...

Most Popular

Related Articles