Health Information Management

Consider internal auditing options

HIM-HIPAA Insider, April 6, 2010

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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 for more information or to purchase a copy.

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