Book excerpt: What’s a coding audit?

By Rose T. Dunn, MBA, RHIA, CPA/CGMA, FACHE, FHFMA, CHPS

While I prefer the use of the term “coding review,” the industry commonly uses the term “coding audit” to describe the practice of reviewing the accuracy of code assign­ment. These audits are done based on the documentation in the patient’s record at the time of the review, which is then compared against the codes reported on that claim.

The review should encompass more than solely coding accuracy but also identify:

• Conditions that are documented and not coded (coding omissions). These additional conditions may lead to a comorbidity/complication (CC) or major CC (MCC), which increases the degree of morbidity or risk of mortal­ity for the patient, thus painting a picture of the patient’s severity of illness. This could also contribute to an additional hierarchical condition category or ambulatory payment classification, which may increase reimbursement.
• Opportunities to seek further clarity and specificity for conditions that were documented and coded with limited specificity, or unspecified, or conditions implied based on tests performed, medications administered, and other clinical indications, but not documented by the physicians. These are cases in which physician queries may have enhanced the coding process but were not issued.
• Documentation issues for one or more providers, or documentation issues fostered by the electronic health record, or templates/forms designed for provider use.
• Charges that appear on the claim but are not supported by the documen­tation in the record.

Editor’s note: This article is an excerpt from The Essential Guide to Coding Audits.