Submitted by: Grace Doumanian, RHIT, CCS, and Angela
Hulvey, RHIT, CCA
FHIMA Consumer Engagement Committee
What is medical auditing? AAPC defines a medical audit as “a systematic assessment of performance within a healthcare organization" (AAPC, 2022). Most audits look at payer reimbursement and a facility's payment for giving medical service. These audits performed keep coding and billing errors in check. Audits are important for the consumer as they find inaccuracy issues caused by a lack of medical documentation or the creation of erroneous billing. Medial audits prevent fraud caused by habitual overcoding and overbilling, which can help keep insurance costs low.
Medical coders specializing in auditing must validate the diagnostic-related group (DRG). A nurse with a background in coding can perform clinical validation. The two work together to confirm that appropriate assigned diagnostic and procedure codes accurately reflect the care and treatment provided as well as the condition of the patient. DRG assignment impacts facility reimbursement and the case mix index (CMI), where the average relative DRG weight of an inpatient discharge reflects the complexity and severity of the illness of the facility's patients.
DRG audits can be done internally by an employee of the hospital, or the insurance company will flag target DRGs sent to an outside company. This outside company is contracted with the insurance company to ensure the appropriate DRG is assigned and properly paid. If the insurance company determines there was an overpayment to the facility, the facility must reimburse the payer.
Target DRGs claims involve complications, comorbidity (CC), major complications, and comorbidities (MCC) that impact reimbursement. The presence of two or more diseases (comorbidities) and complications can greatly impact a DRG and the reimbursement with a possible flag for an audit. It is important to validate these specific conditions and confirm the current treatment. Secondary diagnosis codes must meet the Uniform Hospital Discharge Data Set (UHDDS) as a secondary diagnosis which is "those conditions that coexist at the time of admission or develop subsequently, and that affects the patient care for this current episode of care" (ACIDS, 2022). During a patient's stay, conditions require treatment and monitoring.
The patient's medical record documentation must be consistent. If documentation is inconsistent, incomplete, or inaccuracies, the facility should query the attending physician to validate the condition (AHIMA, 2019). Documentation in the query should support the diagnosis/condition in question. Medical audits are beneficial as they decrease patient risk and raise a facility's reliability. Patients can trust that the facility providing their care is doing the right thing and accurately documenting their treatment. Providers benefit from medical audits as these audits reduce habitual overcoding and overbilling and ensure accuracy.
References
AAPC. (2022, May 2). Medical
auditing. AAPC. Retrieved December 13, 2022, from https://www.aapc.com/medical-auditing/medical-auditing.aspx#whatDoesaHealthcareAuditorDo
Guidelines for achieving
a compliant query practice (2019, n.d.). Guidelines for Achieving a
Compliant Query Practice (2019 Update) / AHIMA, American Health Information
Management Association. (n.d.). Retrieved December 13, 2022, from https://bok.ahima.org/doc?oid=302673#.Y5iDtsvMJUs
Q&A: Primary,
Principal, and secondary diagnoses. (ACDIS, n.d.). Retrieved December 13,
2022, from https://acdis.org/articles/qa-primary-principal-and-secondary-diagnoses-0
