Although all providers should have a Compliance Program, it seems that mostly larger groups have them in place and even then, to varying degrees. Many practices have some form of internal validation of a coder’s work; most of the time, a coding supervisor may review a team member’s work, or managers may rotate clinician assignments among coding staff – in theory – to include another perspective on the work. These are a good start but we must acknowledge their limitations in light of the three components for effective auditing programs:
Knowledge
The individual conducting oversight audits should have current knowledge of proper medical coding, documentation and clinical guidelines. The person should regularly conduct chart reviews and receive ongoing education on the nuances of medical conditions, the expectations for evidence and proper support, and how these elements should be captured in the medical documentation. The auditor must know coding guidelines and be able to assess if they have been properly applied. Supervisors who are mostly removed from day-to-day reviewing responsibilities may not be current on important changes and shifting charting patterns. The coding grapevine is sometimes the source of lore, and coders pass along tips they have heard or perspectives they honed with previous employers that are not necessarily sound or accepted.
Independence
We used to believe that employed coders were less inclined to challenge incorrect coding out of fear of unemployment, but we have seen this subtlety reflected among contracted coders as well. Effective auditors are independent. They call a wrong code a wrong code, and challenge incomplete documentation. For an audit to be reliable, the auditor must be free from real or perceived pressure to overlook inaccurate codes or faulty documentation. Sometimes that entails disagreeing with a clinician, which some are loathe to do. However, in our experience, when provided solid information from trusted sources, most PCPs will change any faulty coding behaviors and chart correctly. We have encountered numerous MRA coders who live in the groove of old parameters and grapevine news, and are unable to convey current information and/or have lost credibility with the providers. For this reason, using an external auditing company could be beneficial in assessing to what degree, if any, these issues plague your practice.
Neutrality
Independence goes hand-in-hand with neutrality. Workers cannot be expected to fairly audit themselves; after all, if they are making mistakes, they will not identify them as such during a review. Similarly, some supervisors may also be operating with erroneous information or mistakenly believe that a coder’s performance issues reflect negatively on their leadership. Any of these issues put your whole audit protocol in a questionable light.
In the quest for proper coding and risk adjustment oversight, it’s important to periodically spot-check the work of your MRA department. Our company has performed several of these audits, sometimes in preparation of coders’ performance evaluations, and found error rates in excess of 40 to 50%, which could spell disaster for a medical practice or group.