CODING AUDIT AND UTILIZATION REVIEW POLICY AND PROCEDURE

Policy:

ABC Clinic is committed to ensuring that coding and billing activities are in compliance with all federal and state regulations. Periodic coding audits are performed to identify deficiencies in the claim development and submission process. Audits also will enable ABC Clinic to appropriately target and measure the effectiveness of its educational efforts.

Procedure:

Coding Audit

  1. The IT Manager will run a Provider audit query of medical coding/documentation for June-November and December- May each year.
  2. HIS Staff will:
  3. Randomly select 10 patient records of dates of service for each provider, by provider number to review medical coding/documentation.
  4. For professional volunteers: Auditing on an as needed basis.
  5. Visit type examples:
  6. Annuals
  7. Illness visits
  8. Procedure visits
  9. Print out a copy of Office Visit Note or Procedure Note from EHR
  10. Highlight the selected patient visits on the audit query report.
  11. Place the documentation with the audit query report and send to coding auditor within one week of receiving audit query report.
  12. Provide copy of query showing date records sent to coding auditor to Compliance Officer.
  1. The coding audit results are sent to the Compliance Officer for review and analysis.
  1. If necessary, the coding auditor will be invited to a provider meeting to provide coding education.
  1. The medical coder is provided the results of the coding audit and attends all coding education meetings. Unless otherwise noted at the provider meeting or by the medical director (see below), the medical coder will correct all codes that were identified by the auditor as being incorrect, route them to the appropriate provider for signature, and resubmit the claim.
  1. Each providerreceives his/her audited records and correlating results for review no less than two weeks prior to the provider meeting. Questions, comments, and concerns about results must be brought to the meeting.
  1. If a provider disagrees with the auditor’s findings, resolution should be sought at the meeting. (See workflow attached)
  2. If the provider and the auditor cannot agree, the issue will be brought to the medical director to determine if:
  3. The code will be changed by the medical coder, routed for signature to the medical director, and the claim will be resubmitted or;
  4. The code will remain the same. Thorough documentation of the reasons behind the medical director’s decision to maintain the provider’s code will be filed with the Compliance Officer and maintained for seven years.
  5. If the providerand auditor reach an agreement:
  6. The code will be changed by the medical coder, routed for signature to the provider, and the claim will be resubmitted or;
  7. Documentation will be amended to match the code. The medical coder will be alerted not to make the coding change as listed on the audit report.

Coding Utilization Review

  1. At the end of each year, the IT Manager will run a utilization query for the previous year, containing the medical codes used for patient encounters for all medical providers.

2. He/she will forward the query to the HIS staff to send to the coding auditor.

3. The coding auditor performs a review of the patterns of utilization of medical codes compared to national trends.

4. The coding auditor forwards the report of the review to the Compliance Officer who shares the information with the providers and the leadership team.

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