The checks and balances of an edit, review, and audit process

by Keri Hunsaker

Prospective Review or Retrospective Audit – which is more effective?

Coding accuracy reviews and audits are designed to ensure health care organizations are providing the most accurate and compliant representation of the patient care provided. There are multiple ways in which coding and compliance functions provide checks and balances to ensure coding accuracy, including custom edits, second-level reviews and retrospective audits. When looking at these different processes, which is more effective for ensuring coders are accurate and working through the most complex coding issues?  The answer is all of them. Each function provides a valuable approach to ensuring the highest coding accuracy throughout the coding session, along with the “balance” of a retrospective audit that targets high risk coding areas, and/or the need for additional coding education. 

An effective edit and prebill review process.

An effective coding accuracy program begins with the coder. This can be complicated, as coders are tasked with the challenge of knowing the latest coding policies, reviewing documentation, understanding and applying the coding rules to specific patient documentation, and doing this process quickly and accurately. Although technologies such as computer-assisted coding have certainly helped, there are always opportunities for improvement. In addition to complex coding requirements, quality initiatives (e.g. mortality reviews) involve additional attention, ideally prior to bill submission.  And of course, all of these tasks must be completed within the suggested CMS guidelines of 95% accuracy or higher, and the organization’s timeframe for bill submission. 

A well thought out prospective custom edit and review process will align accuracy within the coding workflow. Ideally, the further upstream custom edits and reviews take place, the more efficient this process is for the coders and the reviewers.  Custom actionable edits, specifically designed to address high risk coding challenges, may be established throughout the coding workflow. To be most effective, the custom edits should be targeted to address specific high risk coding areas as part of the coding workflow, at the point of coding. 

A second level review can also be leveraged as part of the coding workflow. As specific issues are identified as needing a “second pair of eyes” the second level review, especially within the existing coding workflow, allows additional checks for coding and documentation accuracy. Ideally the second level review allows for two-way communication and documentation between the coder and the reviewer with minimal additional hold times.

The ultimate goal for custom actionable edits and prebill reviews is to ensure coding accuracy and completeness, within the coder’s workflow, based on an organization’s specific high-risk areas, with minimal disruptions or delays.

Balance with a retrospective auditing program.

Even with an effective custom actionable edit and prebill review process, retrospective audits are still a compliance requirement for HIM departments. A retrospective audit allows a more comprehensive and in-depth audit on a larger data set, providing a broader look at trends and potential coding problem areas. The compliance manager or audit manager can take appropriate action to address audits through education or other means. The compliance manager or auditor also can observe trends and identify areas of improvement over time. In addition to identifying trends, the audit can identify issues for resolution on the front end, either through a custom edit or a second level review.

The checks and balances of the complete edit, review and audit process.

Each of these functions are useful on their own. When combined, this comprehensive and powerful process addresses coding accuracy from every angle.

1.Edits, at the point of coding, resolve coding errors, minimizing the need for rework or worse case, denials.

2.Second level, or prebill reviews, allow the “extra eyes” to ensure complex issues or quality issues are documented and coded accurately, reducing the chance for missed revenue or long-term holds.

3.Retrospective audits ensure that trends are moving in the right direction. A retrospective audit can also identify areas that are better addressed during the coding process, again, reducing potential issues.

The original question, which is more effective…a prebill review or retrospective audit? For the highest coding accuracy and revenue integrity, the answer is all of the above. 

Keri Hunsaker, Marketing Manager for the 3M Health Information Systems, is responsible for reviews and auditing programs within revenue cycle.