Medical Coding Auditing for Compliance and Billing Efficiency

The growth in healthcare consumerism places greater responsibilities on care providers to adhere strictly to regulatory rules, posing significant challenges to handling medical coding efficiently. Accurate documentation of medical records appropriate assignment of billing codes, and precise charging of insurance providers for services provided ensure the financial stability of healthcare, which are also the issues healthcare professionals deal with frequently. However, care providers rely on staff or access billing and coding auditing companies to handle the job without reviewing the claims before submission. Moreover, they often lose the proper payments in exchange for the services provided because they need to oversee the medical coding patterns and overall practice performance. The process of medical coding auditing serves as the crucial linchpin for maintaining the delicate balance between adherence to regulatory standards and a seamless flow of revenue generation. Hence, healthcare providers grapple with the need for comprehensive and productive medical coding audits to keep their practice updated with current standards and valuable revenue cycle management. In his article, Kenneth T. Hertz, C.M.P.E., a Consultant for the Medical Group Management Association, says that "an audit cycle in medical coding is one of the best ways to ensure the stability of healthcare practice. Conducting an audit will help you identify what best works for your practice, will help strengthen those areas that need strength, and will help identify those areas that need improvement. Moreover, all doctors must understand that their practice is part of a business and take simple and prudent steps to ensure it runs properly."
This article will adequately shed light on why it is significant to monitor and audit medical record documentation and coding structure as the way to successful complaint practice and avoid billing errors to prove efficiency in revenue.

What is medical coding auditing, and how is it conducted in healthcare?

A medical coding audit is a detailed check-and-balance system in healthcare coding to ensure practice efficiency and improvement. The process is conducted by reviewing the patient's medical records by medical coding audit. The primary purpose of coding audits is to evaluate the physicians' code selection for diagnosis in documentation and ensure the completeness and accuracy of coding.
The process of conducting medical coding auditing is determined by the type of audits and auditors with different characteristics and benefits for your practice. Following are some of those factors to decide which one your practice needs most:

• An external coding audit will help you understand the practice's impact on revenue, while an internal coding may not.
• An internal coding audit may be conducted by a coding staff trained in auditing for compliance.
• The organization members conduct an internal audit. However, an external audit is performed by the members who are not part of the organization but usually a third-party auditor.
• External auditing will bring ample experience and an amount of precision that internal auditors may miss.
• External auditing will help your practice with more objective results acceptable to providers and other staff members.
• An internal audit requires a certified and experienced staff to conduct an audit within a considerable time. However, an internal audit does not tell the productive if the staff handles other responsibilities.
• External audits conduct a baseline as an ample for various levels of E/M services and surgical procedures to measure the coding complaint for each practitioner.
• Depending on the outcomes of baseline audits, external audits can be conducted quarterly, biannually, or annually. However, an internal coding audit should be performed annually if the issues hindering success have been identified.
• Organizations are apt to perform internal and external audits to maintain complaints inside the medical coding practice since hiring a full-time internal auditor may become cost-prohibitive for small organizations. Moreover, they face the challenge of finding a trained and experienced in coding audits for compliance.

The Significance of Medical Coding Auditing and Revealing Factors in Coding Structure

The Healthcare Financial Management Association (H.F.M.A.) report claims that the denial amount rate to healthcare providers will be about $235 billion in 2021. Medical coding audits help providers eliminate coding errors in practice and denial rates by tracking the practitioners' performance. One of the crucial issues healthcare providers can face while not conducting regular audits is to expose the practice to compliance risk along with revenue loss. OIG audit of the Healthcare Financing Administration (HCFA) revealed errors in 30% of all claims paid by HCFA, accounting for approximately $23.2 billion annually, or 14% of total Medicare fee-for-service. One-third of the documentation errors were because physicians failed to respond to requests from auditors to submit documentation.
Moreover, according to experts' reviews, every one of the five claims is either delayed or denied. To avoid denials and discrepancies in the process, coding audits help professionals dig down into the current coding issues and get knowledge on streamlining the process with novel policies. An Office of Inspector General (OIG), in his volume "Compliance Program Guidance for Individual and Small Group Physician Practices," emphasizes the following risk areas for physicians to avoid.

• Billing for services and procedures not provided
• Submitting claims for medical supplies, equipment, and unreasonable services
• Provider identification number misuse
• Unbundling multiple component services and billing each as a single
• Failure to correctly assign modifiers
• Upcoding the level of services delivered

Medical Coding Auditing Reveals Various Levels of Incorrect Services Including:

• Incorrect use of C.P.T. Codes
• Detect inappropriate diagnosis
• Under-coding and over-coding
• Improper use of modifiers
• Verify supporting documents to ensure the provision of medical necessity of service provided
• Problems in compliance areas
• Improper documentation in billing
• Physicians' lack of proper understanding and coding guidelines
• Allow physicians to compare their coding practice with the practices of their peers
• Reveals the problems with medical records

Why should medical coding be compliant with healthcare regulatory bodies?

Preventing sensitive patient information is paramount for providers from various cyberattacks in the digital era. However, providers' compliance with their practices according to the HIPAA and H.I.T.E.C.H. compliance rules ensures adequate data security from these attacks and threats.

HIPAA Roles in Healthcare Compliance - the shift from printed documentation and records to digital transformation, such as electronic health records (E.H.R.s) for PHI, is one of the triggering factors that coding practices need regular audits. HIPAA brings various advantages to aid this shift. Making a complaint about the coding practices according to HIPAA rules helps practitioners ensure confidential data is secured and transferred securely. Moreover, electronic recording and data transactions among various healthcare bodies place everyone on the same page in providing the practice's accuracy and improvement.

HITECH-Complaint Practice and Rules - medical coding being H.I.T.E.C.H. Compliant ensures access to the correct patient records and effective communication of sensitive patient data with the right people to improve collaborative treatment. Practitioners complying with HIPAA and H.I.T.E.C.H. must take several steps to secure and sustain sensitive patient information, such as managing, storing, and sharing patient data and other confidential information in care practice.

Potential Benefits of Medical Coding Auditing for Compliance and Billing Efficiency Enhanced accuracy and error reduction

The National Healthcare Anti-Fraud Association (N.H.C.A.A.) reports that medical billing errors and fraud cost the United States healthcare system billions annually. However, regular medical coding audits significantly impact error reduction and billing inaccuracies and save both healthcare facilities and patients from financial burden.
Upcoding is one of the other everyday activities considered fraudulent that many healthcare organizations and providers conduct to maximize their practice revenue from insurance companies and government centers such as Medicaid and Medicare. However, auditing helps practitioners efficiently reduce the risk of upcoding along with using efficient digital software to identify under-coding or upcoding.

Increased Revenue and Reimbursement

The American Health Information Management Association (A.H.I.M.A.) reports that an efficient coding audit program can increase coding accuracy by up to 15% by translating into higher reimbursement rates and improved revenue cycle management. Compliance with coding standards ensures that healthcare providers receive appropriate compensation for the services delivered and boosts billing efficiency with coding audits.

Regulatory Compliance

Regulatory changes are inevitable in the healthcare context. Compliance with the Health Insurance Portability and Accountability Act (HIPAA) and the International Classification of Diseases (I.C.D.) coding systems is vital. One of the studies in the Journal of Medical Internet Research (J.M.I.R.) highlighted that coding audits help healthcare organizations stick to these evolving regulatory requirements, reducing certain legal risks.

Enhanced Practitioners Practices

Medical coding audits streamline various internal processes and reduce the administrative burden of correcting errors post-submission. According to a survey by the Healthcare Information Management Systems Society (H.I.M.S.S.), healthcare facilities investing in regular coding audits reported a 20% increase in operational efficiency.

Billing Accuracy and Reduced Error Risk

The Journal of the American Association (J.A.M.A.) reported that billing errors in healthcare can range from 7% to 80%. However, if conducted properly, medical coding audits reduce billing inaccuracies considerably. Providers can ensure an appropriate submission of claims anytime and minimize the extra workload for administration.

Quality Care Delivery

Medical coding accuracy plays a pivotal role in maintaining patient care standards. A single error in the process can result in incorrect treatment, delayed care, or financial drain for patients. The Healthcare Financial Management Association (H.F.M.A.) emphasizes that coding audits facilitate better patient care by ensuring accurate and timely payment and enabling providers to focus on delivering optimal care.

Steps and Best Practices to Follow in Medical Record Documentation and Compliance

Below are OIG's guiding principles and recommendations in coding compliance programs that help practitioners document records accurately and appropriately as per the level of service delivered.

• Timely practice, accurate and complete documentation
• Connecting appropriate diagnosis with appropriate procedure code
• Using appropriate diagnosis code for examination and patient history
• Using appropriate modifiers
• Identifying other insurance coverage while billing Medicare

Recommendations

• Complete and legible medical record
• Accessible past and present diagnoses in the medical record
• Providing rationale in case of not documenting ancillary services easily inferred by independent reviewer
• Identification of appropriate health risk factors
• Documentation of patient progress, response to any changes in treatment, and any revision
• There must be a documented reason for each patient encounter with relevant history, physician examination results, prior diagnosis test results, clinical impressions, assessment, diagnosis plan of care, date of service, and legible identity of observer.
• You can communicate with experienced medical coding auditing companies and efficiently secure practice compliance and revenue.

What is the job of a medical coding auditor in healthcare?

Holding specific degrees and qualifications, a medical coding auditor is an administrative professional in the industry for checking medical coding and billing information accuracy, compliance with healthcare regulations, and suspicious activity. The job of a medical coding auditor is to review medical data and documents in any area to improve accuracy and enhance efficiency. They also examine patient records to ensure every element of the practice is documented for billing inventory. As per the purpose of their job, coding auditors primarily work to ensure regulations compliance and efficiency of the practice rather than focusing on coding and billing for records.

Can I trust a medical coding auditor to make my practice worthy?

Providers can rely on internal medical coding auditors to streamline their jobs for compliance and efficient billing. However, several precautions are needed to take before hiring one. A professional medical coding auditor with adequate qualifications and certification from A.H.I.M.A. and A.A.P.C. can assist you. You must also ensure that they own a certain associate degree in medical coding or a related field and a few years of experience to handle the complexities of auditing for compliance and billing efficiency.

How can I become a medical coding auditor?

The speedy healthcare consumerism has posed various challenges for practitioners along with medical coding auditing jobs. To become a reliable partner in coding audits for compliance, candidates must ensure they have the necessary education, professional certifications, and skills and knowledge. Moreover, evaluating an organization's financial records, statements, and internal procedures to express an opinion fairly and accurately requires you to stick to high ethical standards, including integrity, independence, objectivity, and confidentiality.
Furthermore, you can also attain several medical coding auditing courses offered by authorized certifications such as C.P.M.A., designed for experienced coders, and provide training on multifaceted components of medical auditing. Moreover, the C.P.M.A. training course helps you cover medical record standards and guidelines on documentation, compliance on coding and documentation, concepts on coding and reimbursement, audit scope and statistical sampling methods, medical record audit abstraction, and category risk analysis and communication.

Outsource Medical Coding Audit Services with MedsIT Nexus Billing and Coding Efficiency

Are you dealing with the difficulty of complex monitoring and auditing medical coding practice for complaints, or are you concerned about the draining revenue rates for your practice? Look for experienced and talented medical coding auditors at MedsIT Nexus who aspire to cater to all your practice needs with ample skills and experience to make your job easier. Leveraging the latest tools and technologies, including medical coding auditing software, helps us deliver the best quality and perfection. Our approach is error-free, and we know how to audit various procedures, including:

• Auditing proper placement of services
• Auditing improper usage of C.P.T. Codes
• Auditing incorrect diagnosis
• Rectify and cluster bundling issues
• Auditing and monitoring incorrect use of modifiers
• Auditing operative reports
• Identifying and ensuring accuracy in coding and documentation
• Identifying trends and practice deficiencies
• Recommend the best after-audit results