The role and relationships are nearly similar to that of healthcare quality assurance and medical coding
auditors. Assuring quality in providing patient care broadly in every aspect of healthcare practice is
paramount for professionals, and medical auditors play a central role in ensuring integrity, accuracy,
and quality of healthcare services in healthcare quality assurance programs. More importantly, the
objective of such coding audits as part of quality assurance programs in healthcare is to ensure that
coding practitioners perform practice duly per the current standards and policies set by regulatory
bodies. According to OIG, healthcare organizations and hospitals must conduct at least one audit
annually. Moreover, the Centers for Medicaid and Medicare Services (CMS) and OIG recommend professionals
to have their practice reviewed by third-party auditors independently to have objective
rather than subjective results for improvement. Hence, auditors emerge as crucial bridges connecting the
dots between coding accuracy and high-quality care delivery to patients. By detecting errors in practice
and causes of denials, these experts prove to be the essential components offering areas of improvement
and healthcare survival in the long term.
In this comprehensive guide, we will offer explanations of the crucial role medical coding auditor
certification holds in healthcare quality assurance and primarily in providing quality care and revenue cycle management.
Quality Assurance in Healthcare is a systematic approach to deliver high-quality treatment and services, safety, and efficiency. It encompasses various steps and strategies aiming at preventing and detecting errors, ensuring compliance with standards and regulations, and continuously improving the care delivery to patients. Dr. Linda Aiken, Professor of Nursing and Healthcare Management, states that quality assurance in healthcare is the foundation upon which trust is built between care providers and patients. It involves not only adherence to clinical standards but also the ethical delivery of care. Thus, ensuring quality is not a choice for providers but an obligation. Moreover, the concept is about achieving consistent and predictable results in healthcare. It's the commitment to providing the best care anytime. It's not just about fixing errors but correcting them in the first place. Some of the common characteristics of QA are:
QA in healthcare is a paramount concept shaping the delivery of medical services and, in addition, the well-being of individuals. Dr Robert Wachter, Author of "The Digital Doctor," states that Research consistently demonstrates that quality assurance interventions can lead to significant improvements in healthcare outcomes. The evidence underscores the importance of effective QA programs. Some of the fundamentals of QA are:
Patient safety - Through protocols, regular checks, and reviews, providers reduce the
number of errors, infections, and adversity of events, ultimately saving lives and ensuring patient
safety.
Improved clinical results - By monitoring and improving performance, healthcare
institutions can enhance the effectiveness of treatments, leading to better clinical outcomes.
Enhanced patient experience - QA ensures that patients are treated with respect,
receive clear communication, and have their needs addressed, leading to improved patient experience.
Regulatory compliance - Healthcare is highly regulated, and non-compliance can have
severe consequences. QA programs ensure adherence to legal and ethical standards, securing patients and
providers.
Cost efficiency - By minimizing errors and optimizing processes, healthcare
institutions can reduce costs and allocate resources more effectively.
Trust and reputation - A commitment to QA helps build and maintain the trust that
patients and their families place in care providers. Consequently, positive patient experiences and
outcomes enhance the reputation of healthcare organizations.
According to a 2016 indexing report from the California Association for Healthcare Quality, administrative costs comprise about 15% of all healthcare expenditures- well over $300 billion annually. Coding expenses count as one of those administrative costs in healthcare. However, accuracy is essential to determine the faster results in attaining predetermined reimbursement. In contrast, an ill-performed practice non-compliant with quality standards will not benefit providers and the organization. Medical Coding Auditors in the QA process offer a safe ground for quality care delivery and improvement in overall practices.
The medical coding accuracy falls under the standard of 95% accuracy. Being the most significant element of medical coding and ensuring avoidance of compliance issues in practice, accuracy ensures the overall safety of patient care and record documentation. By comprehensively reviewing and verifying the coded data within medical records, medical coding auditors are the guardians of data accuracy and the cornerstone of healthcare QA.
Quality assurance in healthcare is inextricably linked to the completeness and integrity of clinical documentation. Medical coding auditors best practices ensure efficiently that clinical records are not only comprehensive but accurately translated into coding. Accurate coding based on complete clinical documentation is essential for healthcare quality and patient safety.
Ensuring compliance with healthcare regulations is one of the primary duties of certified coding auditors. Compliance with standards such as those governed by the Health Insurance Portability and Accountability Act (HIPAA) is not only a legal requirement but essential for maintaining patient privacy and data security as vital aspects of quality healthcare delivery. Moreover, staying compliant with practices is challenging, considering the release of continuous updates. Coding auditor certifications help professionals improve the practice by applying new codes and changes as they identify new laws, regulations, payer rules, and any other issues that may affect the practice specialty.
The financial aspects of healthcare are inherently linked to the quality of care. Medical coding auditors ensure the healthcare organization receives appropriate reimbursement for the services rendered. Such financial integrity strengthens the ability to maintain high-quality care services and invest in advanced technologies and staff training.
Auditors' detailed review of healthcare documentation, claim forms, and Explanation of Benefits (EOBs) documents allows them to identify discrepancies, coding errors, and billing irregularities. By detecting and resolving these errors, they contribute to the overall quality assurance efforts of the institution.
Medical coding auditors engage in proactive performance improvement by identifying patterns in coding denials. These patterns are instrumental in assessing the effectiveness of healthcare processes and allow professionals to implement corrective measures and enhance the quality of care.
Auditors contribute to quality reporting and analytics by ensuring that data used for quality measurement and performance evaluation is accurate and consistent. The data is used for monitoring and improving patient health and the overall quality of healthcare services.
The healthcare industry is in a consistent state of evolution, with novel technologies and treatments emerging constantly. Hence, there is a need for regular coding auditor training to continuously update their knowledge and skills to efficiently adapt to these changes and ensure that coding and billing practices align with the latest developments in healthcare.
The demand for quality coding is rising since health threats are rising,
and consumer expectations grow regarding quality care delivery and better patient care. The Bureau of
Labour Statistics reports the number of positions in medical records and health information technicians,
including medical billers and coders, will increase by 13% between 2016 and 2026. However, maximizing
coding value requires quality assurance feedback provided by professional coding auditors in the entire
auditing process to ensure all coders are on the same line of meeting the criteria of standards,
improving various operations, and ultimately positively impacting the practice's revenue.
Medical coding auditor responsibilities are also rising along with the coding demands in institutions.
Technology has shifted the way audits are conducted because of the sheer volume of data, automation, and
demand for a forward-looking approach to audits. Thus, the practitioners must adapt to these new coding auditor technology skills and expertise to execute high-quality audits. Some of these
technologies include:
MedsIT Nexus Medical Coding Auditing services ensures unparalleled healthcare quality assurance through advanced coding and auditing solutions. With strict adherence to HIPAA-compliant practices and the latest technologies, our experts in auditing guarantee precise and attentive coding audits to evaluate the standards of accuracy and compliance in the healthcare industry. We streamline your auditing workflow by automating code validation, maintaining a thorough audit trail, offering compliance alerts, and providing education resources. Connect with us and discover how MedsIT Nexus Medical Billing and Coding and auditing expertise optimize your healthcare practice and excel towards the future of integrity.
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