Best Practices For Medical Coding Auditors To Use

Errors in practice, upcoding or under coding, fraud or abuse in healthcare practices and in medical billing are counted among the severe considerations for the government's rising investigations, triggering care providers, on the one hand, to keep alert on preventing their practice from being the next target and consequently, introducing ever-evolving standards for providers to ensure transparent and accurate medical coding compliant with the policies of healthcare regulatory bodies. An average of one in seven claims are denied due to errors that can be easily fixed if audited efficiently before being institutionalized. Medical coding auditors emerge as significant assistance to the practice in identifying efficiently various malpractices and discrepancies in coding practices, documentation quality, and billing accuracy by offering feedback for continuous quality improvement in the process. As evidenced by the Bureau of Labour Statistics, there is a growing need for specialized individuals of 8% in employment for medical records and health information technologists, including medical code auditors, between 2020 and 2030. Moreover, a well-conducted coding audit performed by a qualified coding auditor helps professionals provide quality patient care and improve revenue for the organization at increasing levels. Hence, the dynamic world of healthcare not only strengthens the scope of medical coding auditor responsibilities but also increases the demand for required education and qualification to perform audits according to regulatory standards while staying up-to-date with proceeding policies for the practice's success. This guide will reveal some of the best practices for medical coding auditors aligned with the latest industry standards and ongoing changes to ensure a successful process. Moreover, it will provide recommendations on the qualifications and training needed for medical coding auditors to attain a secure practice and career in the growing industry.

The Medical Coding Auditing: Aims and Process

Considering the type and objective of an audit explicitly conducted for an organization, the coding auditors come across several steps in auditing. Auditors determine the sample size and the number of medical records to review. However, the goal of an audit determines whether the sample is targeted or random, and the number also differs as per the type and size of the organization. The smaller organizations can start from 10 to 20 claims as a good start, whereas larger organizations' best choice is to get 20 to 30 claims per provider.

After reviewing the sample for auditing goals and scope, the auditor presents detailed findings along with the root cause analysis to the organizations. Hence, the organizations must ensure that they pay heed to the recommendations of the auditor to investigate the areas requiring improvement and how best they can implement those recommendations to support the system. Moreover, obtaining these equally important results of independent reviews offers several opportunities to optimize reimbursement because coding errors and discrepancies are the leading causes of denials and undervalued services. A separate/ peer review will help providers avoid errors placed unintentionally and institutionalized that can be highly costly in terms of lost charges over time. On identifying an omitted code, no payer pays the payment for the services other than the ones billed.

MedsIT Nexus' efficient medical coding auditing handles auditing procedures appropriately. Our auditing reports address various issues in the coding process by identifying undervalued services and missed charges.

Coding auditors key considerations of conducting an audit are to identify the following:

• Gaps in documentation
• Inconsistencies in payer reimbursements
• Incorrect assignment of medical codes and modifiers
• Incorrect billing of clams according to payer rules
• Any fraudulent activity in practice

Why is medical coding auditing significant in healthcare?

In the United States alone, medical billing and coding errors cost care providers approximately $125 billion annually. However, To adapt the healthcare practice to the growing needs of patients and reimbursement management, monitoring medical coding is paramount. The institutions of OIG and CMS strictly recommend that the provider's practices, including patient medical records and documentation, must be reviewed by independent third-party auditors to acquire unbiased results. Conducting audits regularly, these independent auditors must ensure having appropriate expertise in a clinical specialty, accuracy, and compliance with current regulatory laws, rules, and regulations. Moreover, independent coding evaluation helps professionals reduce potential financial and legal compliance exposure. By utilizing the results of these independent coding reviews, healthcare providers and staff can acquire efficient teaching tools to produce a healthy practice.

Healthcare organizations differ in terms of the occasions to perform an audit. However, the HHS Office of the Inspector General OIG advises organizations to perform medical coding audits annually to ensure it is compliant. Organizations can accelerate auditing more than a year based on specific reasons, including the requirement of its compliance plan. Moreover, the root cause of previously identified errors may determine the particular type of audit case, such as targeted DRG or APC. The consistent accuracy rate recommended by OIG is 95% or higher. Still, organizations can assess the need to conduct a monthly or quarterly audit if the practitioners still need to meet the recommendations.

Why is a medical coding auditor important in healthcare?

One of the essentials of why a medical coding auditor is vital in healthcare is accelerating the validity of reimbursement. Johnson states that auditors working for a payer can question the validity of code, leading to higher reimbursement than warranted. However, it causes payment denials or questions, both proven costly for the provider's pursuit. Coding auditors working for insurers strictly check out the codes on claims and find suspicious coding patterns such as upcoding or higher reimbursement than justifiable. Auditors can also work internally in hospitals or for a medical practice group. Below are described some of the effective medical coding auditor responsibilities that practitioners can also ensure representing as their medical coding auditor resume:

• Evaluate confidential health documents to ensure HIPAA and managed care policy compliance
• Regular interpretation of medical documents, including UB04 claim forms and EOBs
• Review EOBs, verify contract-based payments, and file appeals for underpaid or denied claims
• Examine medical records to assess clinical documentation support for coding and DRG assignments
• Possess advanced knowledge of CMS and provider contract rules
• Process HCFA and UB claims in a production environment
• Generate monthly workload and quarterly savings reports for CMS
• Reorganize the ROI process to enhance efficiency and reduce backlogs
• Monitor systems and alerts related to HL7 and LIS
• Submit additional HCC codes found in medical records to maximize revenue
• Handle doctor tax identification and ICD-10 coding for accurate claim submission
• Code records according to prescribed standards, including ICD-10 and CPT
• Assess documentation in office E/M, surgical, and inpatient E/M coding

The Best Practices for Medical Coding Auditors to Use

Consider High-Risk Areas

Direct your audit efforts toward high-risk areas with the potential for significant compliance risks or substantial financial impact to increase audit effectiveness and ROI.

Work Together with Providers

Resolve the coding difficulties cooperatively to encourage appropriate practices and lessen the need for additional audits in future by:

• Maintaining open communication with care providers
• Share audits regularly
• Collaborate to put remedial measures in place

Track Coding Patterns and Trends

Keep a close look at coding patterns and trends to spot areas requiring more auditing and find areas for improvement with:

• Examining revenue cycle indicators
• Denial rates
• Coding accuracy rates
• Prevent costly issues
• Take proactive measures to address them

Employ a Medical Coding Audit Tool

Adopting a medical coding audit tool streamlines various tasks in the process, including:

• Save time and enable auditors to prioritize crucial tasks.
• Emperors auditors to handle a more significant number of audits in the same time frame
• Optimization of resource utilization
• Consider exploring MedsIT Nexus' efficient medical coding auditing software system to streamline the procedure at various steps.

Examine the Denial Rates

The audit should include rejected claims for staff training and overall practice improvement. Often, the percentage of denials in the audit exceeds those encountered over a given period. Offering auditors valuable insights into the reasons behind claim denials. After all, a primary objective of a code audit is to reduce future denials and make it logical to subject refused claims to more detailed scrutiny than accepted ones.

Medical Coding Auditor Certifications and Skills Required

The rising demand for coding auditing practices in healthcare offers various medical coding auditor jobs for aspirants aiming to grow in their careers. However, several qualifications are required to obtain the status and handle the intricate job of medical coding auditing accurately and efficiently. As per the expert's reviews and recommendations, to be a coding auditor, you must require specific medical coding auditor certifications, including:

• Certified Coding Associate (CCA)
• Certified Coding Specialist (CCS)
• Certified Professional Coder (CPC)

All these certifications have specific eligibility criteria, but you must pass a particular exam to acquire these qualifications. Moreover, these certifications must be credentialed by the American Health Information Management Association (AHIMA) and the American Academy of Professional Coders (AAPC).
In terms of specific skills required, practitioners can avail of particular medical coding auditor training and courses offered by the professional bodies. To acquire the position, they must ensure having strong communication and analytical skills, ability to teach and convey information as they will likely be training and coaching other coders in future.

Take a Step Further and Resolve Your Medical Coding Auditing Needs With MedsIT Nexus

We understand the uniqueness of every organization and offer our coding and auditing expertise accordingly. Our team of certified medical coders has strived for years to help you streamline medical coding and provide quality patient care. MedsIT Nexus Medical Billing and Coding services efficiently cater to the needs of every healthcare business and eliminate inpatient and outpatient coding errors efficiently, detect problem areas, offer necessary training and education, and help providers avoid denials.
Our medical coding audits are uniquely processed for your practice success and efficient at detecting, removing, and preventing coding errors. Utilizing the advanced medical coding auditor software and technology, our auditors expertly review the documents to ensure codes align precisely with the services rendered and are HIPAA-compliant with the current standards and policies.