As a new health information management department director, you want to ensure that your department is adhering to the applicable state and federal coding guidelines and regulations. One way to ensure this is to
conduct regular audits of the coding practices within your department. Audits help to identify any coding errors or non-compliance, allowing you to take corrective actions and ensure adherence to coding guidelines and regulations.
To conduct an audit of your department's coding practices, follow these steps:
1. Define the audit scope: Determine the specific areas or processes within your department that you want to audit. This could include inpatient coding, outpatient coding, evaluation and management (E&M) coding, or any other specific coding types.
2. Establish audit criteria: Identify the coding guidelines and regulations that apply to your department. These may include state and federal regulations, such as the Official Coding Guidelines for ICD-10-CM/PCS, CPT coding guidelines, Medicare guidelines, and any other relevant rules and regulations. Use these guidelines as the basis for your audit criteria.
3. Select audit samples: Randomly select a sample of coded records or encounters for the specific area you are auditing. Make sure the sample size is statistically significant to ensure accurate results.
4. Conduct the audit: Review each selected record or encounter and compare the coded information to the established audit criteria. Look for coding errors, non-compliance with guidelines, documentation deficiencies, and any other issues that may arise.
5. Documentation and findings: Document your findings for each audited record, including any coding errors or areas of non-compliance. Calculate error rates or compliance percentages to quantify the findings.
6. Analyze the results: Review the overall findings from the audit to identify trends or patterns. This will help you understand the root causes of coding errors or non-compliance and determine areas that need improvement.
7. Implement corrective actions: Based on the audit findings, develop a plan to address any coding errors or non-compliance issues. This could involve additional training for coding staff, updating coding guidelines and reference materials, or implementing new processes and controls.
8. Monitor and reassess: Continuously monitor your department's coding practices and reassess compliance regularly. Conduct periodic follow-up audits to ensure that corrective actions have been effective and that coding practices remain in compliance with guidelines and regulations.
By regularly conducting audits of your department's coding practices, you can ensure that your team is following the applicable state and federal coding guidelines and regulations. This will help you maintain accurate and compliant coding practices, which are vital for the financial health of your organization and the delivery of quality healthcare.