Billing and coding audits made easy - HCPro

1 Billing and coding auditsmade easyA supplement to HCPro , Inc. publicationsBilling and coding auditsmade easyBilling and coding audits made easy2 Table of contentsGet on boardLearn the top 10 reasons why performing Billing and coding audits will increase your organization s effectiveness.. 3 APCsMuch of your facility s Billing depends on accurate ambulatory payment classification grouping. Find out how to ensure the accuracy of APC coding .. 4 DRGsIncorrect inpatient coding can affect your hospital s reimbursement by thousands of dollars for each patient admission. Here are eight tips for ensuring accurate diagnosis-related group assignment .. 6 One-day staysGet an 11-step plan to audit one-day stays to verify that your organization admits patients under the appropriate status.

2 8E/MFind out how to evaluate your facility s coding and documentation of evaluation and management services ..10 Same-day readmissionsHere is a nine-step plan for ensuring that your hospital is Billing appropriately for patients who are discharged and readmitted on the same day .. 11 Dear reader: HCPro , Inc., is pleased to present this 12-page report to help you perform Billing and coding audits . Thisspecial report will offer you advice from the experts on auditing for accuracy of ambulatory payment clas-sification coding , diagnosis-related group coding , one-day stay Billing , evaluation and management coding ,and same-day readmissions Billing . This report will serve as a tool to help you put top-notch auditing programs in place.

3 We look forward tocontinuing to provide you with timely, pertinent information and tools to aid in your compliance ,Melissa Osborn, managing editorBilling and coding audits made easy3 Why perform Billing and coding audits ?When considering compliance auditing, most providersfocus on the fact that it must be performed pursuant tofederal government regulations. Instead, try to putauditing in a more positive light. When presenting the concept of medical-record andcoding audits to the administration, governing board,and others, present it as a process that will improve theorganization, rather than as a chore it has to make this shift, offer the following 10 benefits ofmedical record and coding audits :1. Improved operational performedcorrectly, audits should identify all types of errorsand direct you to the root of any coding can also increase productivity.

4 If employeessee auditing as a normal part of their work processrather than as a function that threatens their jobs,they are more likely to perform with a higherdegree of effectiveness and Mitigated damages in the event of an government considers the existence of aneffective compliance program to be a potential miti-gating factor in the event of an investigation. The keyword here is effective. The auditing program mustidentify compliance concerns, create a feedbackmechanism that prevents the same errors from re-curring, and initiate repayment of any funds re-ceived in error. 3. Additional protection against certain legal effective auditing program will likelyuncover potential non-reimbursement related prob-lems that could develop into legal issues, such asrisk-management and quality-of-care issues.

5 Theorganization will then be able to rectify these issuesbefore they develop into full-blown legal Improved data quality complianceauditing is performed appropriately, with the neces-sary feedback, education, and follow-up, it results inimproved data quality. All data users have an inter-est in ensuring that data is More reliable data for reporting and data are essential for reliablereporting and research. Government funds may beawarded to facilities based on certain reportingrequirements. In addition, statistical reporting ofhealthcare data plays a role in the awarding ofgrants for research Improved relations between HIM/ Billing staffand effective audit will identifyerrors caused by physician documentation responsible for poor documentationshould be informed and educated on these issues,and receive regular feedback from health informa-tion management (HIM) Correct reimbursement to the should identify underpayments as well asoverpayments.

6 Because of the improved operationalefficiencies that can result from auditing, many facili-ties have seen an increase in their overall Better relations among all departments andfunctions involved in the reimbursement work better when they understand whythey are doing what they are doing. It is also helpfulif employees understand how individuals in otherfunctions or departments affect their work process-es and how their own work processes affect Enhancement of auditing by current qualityassurance/utilization review take stock of any functions that could enhancecompliance auditing or be used in the compliancemonitoring process before reinventing the A new public relations a suc-cessful auditing system is something to be proud s one more achievement your organization canuse to attract new patients and ensure that patientsreceive the best quality of s note: This article was adapted from the bookCoding compliance : A Practical Guide to the AuditProcess.

7 Go to for more information on this and coding audits made easy4 APCs: Ensure accurate Billing and codingWhen much of your facility s Billing depends on accu-rate and timely use of thousands of HCPCS/CPT codesthat generate Ambulatory Payment Classification (APC)groups, you need to have a system in place to checkyour Billing and coding department s work. Accurateand complete coding is the single most important ele-ment driving your success in the environment of an APC audit is a great way to ensure thatyour organization identifies, monitors, and rectifies in-appropriate Billing practices, which will benefit yourbottom line while simultaneously highlighting potentialcompliance issues, says Jugna Shah, MPH,presidentof Nimitt Consulting in St.

8 Paul, should also conduct periodic follow-up auditsto ensure that the organization has procedures in placeto address issues regarding the quality and accuracy ofthe coding and Billing process, said Janet Kucinski,RHIA, CCS, CCS-P, a senior consultant with HospitalResource Management of at least these main areas in your audit : compliance with coding and claim developmentlaws Policies that affect appropriate and efficient outpa-tient coding , including physician documentationand department processes APC reimbursement losses from improper ormissing documentation and charge-capture problemsThe auditReview the HCPCS/CPT codes currently used by alldepartments performing APC-reimbursed from any departments that don t pass Medicareoutpatient code editor (OCE) edits can serve as yourstarting point for further can organize cases bydepartment or other criteria and then, for furtherreview, select a random sample of cases within eachAPC group.

9 The sample does not need to be large:100 150 cases is usually sufficient. I suggest that youstart by auditing with a random sample before startinga focused audit , says Kucinski. There may be a lot ofopportunities to fix problems you re not aware of. Consider relying on data and edits generated from theOCE to pinpoint areas where claims are showing upwith problems on them. This is a more strategic, unbi-ased approach than attacking known problem areas,says Shah. Moreover, by starting with your highest vol-ume of OCE edits, you have the opportunity to fixhigh-volume problem areas first. Shah stresses that theOCE can help you find your problems, and that thepriority should be fixing them on the front end, ratherthan making quick fixes in the Billing your the medical recordand audit trail of codes assigned by the health in-formation management (HIM) coding staff for each claimselected as part of your review.

10 The printed coding sum-mary from the HIM abstracting system or the encodingsoftware makes the best audit trail, said Julia Palmer,MBA, RHIA, CCS, president of the division of HospitalResource Management. Palmer and Kucinski spokeduring an audioconference sponsored by HCPro , each record, Palmer suggested that you also pullthe UB-92, the hospital itemized bill, and the detailedMedicare remittance advice that shows the CPT codesMedicare received for payment, how those codes werepaid, the APC assignment for each, and any modifiersand units of services, said you have selected your sampleand assembled your tools, review the codes yourorganization submitted to the fiscal intermediary on theUB-92 against the information on the medical compare medical record documentation with thefollowing.