Internal pre-bill audits on your CMS directed claims will give rise to additional pre-bill query opportunities, as well as allow for the spotting of coding/MS-DRG errors before they land in that common working file being data-mined by the RACs as we speak.


The simplest model is an in-house second review by an experienced (lead) coder performed one day after the initial coding – delaying the bill drop by one day, but ensuring compliance with Medicare coding and billing guidelines. Additional review by the lead coder can include a brief examination of the medical necessity component and “admit to inpatient” order verification.


On the outpatient side, surgical CPT coders should be encouraged to hold charts for secondary review about which they have questions or those that otherwise present difficulties. Medicare beneficiaries in the observation status also should undergo a secondary coding chart review-checking for accuracy in status determination (i.e. did the physician actually update the status order from observation status to inpatient on day No. 2, but the billing system still shows observation status?) and thus verifying appropriate use and application of Condition Code 44.


Pre-bill audits also are beneficial for all new coders (or experienced yet newly hired coders) with respect to promoting consistency within the coding staff regardless of years of experience or frame of reference for code application. Focused audits also can uncover disconnects between departments that can be fixed relatively quickly.


For example, assume that a nutritional consultant is documenting BMI in actual numbers, using lab values that support the coding of malnutrition, but the physician is not ordering the recommended supplements or documenting the condition of malnutrition in the chart. The patient has a condition that requires workup (lab values and dietician consultation) and for which treatment is recommended, but this is not carried out because the physician failed to read or respond to the nutritionist’s note.


Lead coders performing internal audits also can assist in other interdepartmental activities such as audits on the core measures’ selected cases, infectious disease department studies, emergency services E/M coding (i.e. coding for which the level initially is assigned by personnel in the ER, but verified by the lead coder), verification of the correct application of CPT modifiers in the ancillary and surgical arenas and even application of device codes (when appropriate).


Post Bill Audits


Post-bill audits also may be performed for a variety of reasons, for example reviewing all CPT breast procedure accounts in the outpatient setting. This unique set of codes and procedures lends itself to a plethora of coding rules misapplications and physician documentation discrepancies that vary from facility to facility. One should remember to audit charts with and without the needle localization procedure. You may be surprised at what you find. All inpatient encounters of less than four days’ stay with a CC or MCC should undergo secondary review.


All encounters of more than four days with a lone CC also should be considered for re-review. Hours of ventilation coding continues to be an area of difficulty for coders, as well as the age-old problem of coding excisional debridement in the inpatient world. Lead coders also can be used to double-check the decubitus ulcer coding for correct stage assignment as well as POA (present on admission) indicator assignment.


Another item for auditors to look for is the presence of “arrows” used by physicians as shorthand for “hypo” or “hyper.” This practice is considered to fall under the category of inappropriate abbreviation, and coders cannot code from documentation (like “arrows”) not found in the ICD-9-CM Index.


Data Mining Abilities Put to the Test


Post-bill audits can be a great exercise for all facilities, allowing them to test their own abilities to data-mine their own repositories. Look for the RAC-targeted DRGs, but also look at outlier cases with long lengths-of-stay and no CC/MCC and/or very short LOS with CC or MCC. Look for odd cases (i.e. a MS-DRG that appears only once in 200 accounts or for an unusual combination of attending physicians versus MS-MS-DRG).


When you begin your own mining, do not be surprised at what you find, instead consider each case to be an OFI (opportunity for improvement). From the findings of one focused audit, spin off to another focus.


No matter what type of audits you engage in, the most important step is coder feedback. Do not delay in sharing both good news and OFIs. Coders have a high desire to participate in the submission of clean claims, so let them know when they are doing so and educate them in their weaker areas. Give feedback daily, if possible, to individual coders, but also offer monthly coder education sessions to the entire group on all findings from the month prior. Do not neglect this step. Well-fed coders are happy coders, so feed them with education.



A cautionary note here: if your internal pre-bill audits are not uncovering OFIs, something is wrong. If your external audits are not uncovering overcoding and/or missed opportunities, something is wrong. If your audits continually return no findings (whether internal or external), it is time to bring in a new group of auditors.


No one’s claims are 100 percent squeaky-clean. Do not be fooled into believing that there isn’t at least some bad data in your bank. There is, and digging and investigating should continue until it is uncovered.


Remember, we must know what we don’t know, and no one knows everything they don’t know.


Find it yourself, or let the Recovery Audit Contractors find it….because either way, I assure you, it will be found.


About the Author


Janelle I. Wissler, RHIA, CCS, CMT, CCDS, is a Manager of Client Audits Precyse Solutions. Janelle was previously the Data Quality Manager for a 1,400-bed hospital system in Florida during the RAC demonstration project and has over 25 years in the HIM profession.


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