CODING


Coding Audits A survival guide BY JESSICA EDMISTON


What are the sounds of silence? Announce a cod- ing audit during your next staff meeting and you will quickly find out.


This feared exercise need not inspire dread. In fact, while a cod- ing audit might seem stressful, it is a


straightforward, valuable learning


opportunity that can position a facility for long-term success in today’s fast- changing, hypercompetitive health care market. Through regular coding audits, ASCs can improve compliance, eliminate inefficiencies and optimize revenue and financial performance. Audits also provide staff with a


snapshot of how they are doing and point to areas where continuing educa- tion might be helpful. And the ongo- ing industry-wide 10th revision of the International Statistical Classification of Diseases and Related Health Prob- lems (ICD-10) transition only under- scores just how valuable these audits are for professional development. The previous version of the International Classification of Diseases was in place for more than a generation, and some coders who used the previous version for decades continue to confront chal- lenges. Audits can further reduce this ICD-10 learning curve, provide valu- able feedback and identify opportuni- ties for improvement. Understanding how coding audits


work, how to prepare for one and, per- haps most importantly, what to do with the results can lessen the initial sting of an audit and turn it into a positive expe- rience that produces lasting results.


The Basics No two assessments are identical, but all typically have several functions in common. First, a review of coding practices usually involves taking a look


at a 5–10 percent sample of a coding case volume. Generally, 95 percent or more of that sample’s coding should be accurate.


Audits can be conducted internally


or externally. When the audit is con- ducted in-house, it is performed to assess the coding team’s skill level and usually occurs on a quarterly or annual basis. In these situations, a represen- tative sample is typically selected and weighted to mimic the facility’s overall specialty and payer mixes, case com- plexity and physician mix; this way, the audited files provide an accurate repre- sentation of the ASC’s overall caseload. Audits also are requested by external


sources. Payers, for example, periodi- cally request audits to determine whether coding errors might have caused over- payments. These 30- to 90-day requests are typically focused efforts designed to determine whether a frequent omis- sion or coding mistake led to improper reimbursements. Management com- panies and other external stakeholders also may request an audit. These routine assessments are frequently conducted by a third party and provide valuable


feedback on the coding team, as well as its individual members.


The Warm-Up


Before an assessment begins, coders should gather all relevant operative (OP) notes, pathology reports, history and physicals and physician queries and provide auditors with any specific payer guidelines, for example, unique, detailed guidelines concerning modifi- ers for implants.


It is not uncommon for different


payers to require different modifiers. For example, one might require a 50 for bilateral procedures instead of an RT, which indicates the procedure was performed on the right side of the body or the right extremity, and an LT, which indicates the procedure was performed on the left side of the body or the left extremity. An ASC that provides its specific requirements for these payer guidelines can speed up the back end of the audit and help clarify coding assignments. And while it never hurts to include outside information, docu- mentation must come from a valid source, such as the American Medical Association or the National Correct Coding Initiative.


Usual Suspects Conducting an internal or external cod- ing review helps ensure that an ASC is running an efficient, compliant opera- tion. The common points of inspection include Current Procedural Terminol- ogy (CPT) code assignments, diagno- sis codes, modifiers and implant bill- ing procedures. The differences among the vari- ous coding classification systems used in ASC billing also are typical points of inspection. For example, while an ASC and a hospital outpa-


The advice and opinions expressed in this column are those of the author’s and do not represent official Ambulatory Surgery Center Association policy or opinion. ASC FOCUS JANUARY 2017 19


Page 1  |  Page 2  |  Page 3  |  Page 4  |  Page 5  |  Page 6  |  Page 7  |  Page 8  |  Page 9  |  Page 10  |  Page 11  |  Page 12  |  Page 13  |  Page 14  |  Page 15  |  Page 16  |  Page 17  |  Page 18  |  Page 19  |  Page 20  |  Page 21  |  Page 22  |  Page 23  |  Page 24  |  Page 25  |  Page 26  |  Page 27  |  Page 28  |  Page 29  |  Page 30