Health Information Management

Tip: Check out these reasons to perform coding audits

APCs Insider, April 26, 2013

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If the thought of the government recouping your payments (often with interest) isn't enough to convince you of the necessity of internal audits, consider other ways your facility could be losing legitimate revenue.

If the physician isn't accurately and completely documenting the services he or she provides, coders can't report them. For example, a physician sees a new patient and takes a comprehensive history, conducts a complete review of systems, and performs complex medical decision-making. However, the physician only documents that he or she "reviewed all systems." That is not enough documentation to credit the physician with a complete review of systems, so instead of being able to code a high-level E/M visit, the coder must downgrade the service to a Level I E/M. That's legitimate revenue lost because of incomplete documentation.
The transition to ICD-10 is another reason to conduct internal audits. ICD-10 requires considerably more specificity than ICD-9. If you haven't audited your charts and your coding, you won't know where gaps exist now and consequently won't have those deficiencies resolved before ICD-10 goes live. If you don't know what is happening now, how can you be prepared for later?
The tip is adapted from “New molecular pathology coding still complex” in the April Briefings on APCs.

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