Question

5.12 Fraud and abuse focus Subdomain V.C.1 Identify potential abuse or fraudulent trends through data analysis Subdomain V.C.1 Determine policies and procedures to monitor abuse or fraudulent trends New to your role as revenue cycle manager, you are nonetheless surprised to learn that there is no formal process in place for isolating potential areas of compliance concern. You recognize that this would generate a focused approach for internal or external auditing, leading to identification of coding compliance concerns and opportunities for coder education. Recommend to the coding supervisor a minimum of four best practices for determining focus areas for auditing and monitoring of coding compliance References AHIMA, 2008. Benchmarking Coding Quality, http://campus.ahima.org/audio/2008/RB072408.pdf Hunt, T. J. 2016. Clinical Documentation Improvement and Coding Compliance Chapter 9 in Health Information Management: Concepts, Principles, and Practice, 5th ed. Oachs, P. and A Watters, eds. Chicago: AHIMA

Answer 1

Four best practices to determine the focus areas for auditing and monitoring coding compliance are:

• Establish records coded without a discharge summary, which during audit had the discharge summary, and had identified coding recommendations depending on patient details in the discharge summary, are referred for rebilling and identified as a compliance issue with a follow-up action plan.

• Review internal coding policies annually based on the reason identified for decreasing quality scores and coders should be educated regularly.

• Assessment of noncompliance issues; the types of noncompliance and the number of occurrences of these using data collection and analysis and based on this the focus area can be determined.

• Electronic compliance checks should be conducted using specific software meant for the purpose, which is a really good asset for any internal auditing process. Fraudulent trends can be eliminated by this process.