Purpose of Coding Audits
A coding audit program systematically reviews coded claims to verify accuracy, identify patterns of error, and reduce compliance risk. RHIA candidates should understand that coding audits serve dual purposes: protecting the organization from fraud and abuse exposure while also identifying missed reimbursement opportunities caused by undercoding.
Types of Coding Audits
- Prospective audits, reviewing claims before submission to catch errors proactively
- Retrospective audits, reviewing claims after submission and payment
- Focused audits, targeting a specific coder, service line, or high-risk code identified through data analysis
- Random sample audits, providing a general assessment of overall coding accuracy across the department
Selecting Audit Samples
Effective audit programs use data analytics to identify outliers, such as coders or providers with unusual coding patterns compared to peers, or codes flagged in the OIG annual work plan as high compliance risk. Random sampling is also used periodically to establish a baseline accuracy rate across the entire coding staff.
Conducting the Audit
Audits typically involve an independent reviewer, either an internal auditor uninvolved in the original coding or an external contracted auditor, comparing the original documentation against the codes assigned to identify discrepancies. Findings are categorized by error type, such as principal diagnosis selection errors, missed comorbidities, or unsupported procedure codes.
Reporting and Corrective Action
Audit results should be documented in a formal report identifying overall accuracy rates, specific error patterns, and financial impact where applicable. When errors are identified, organizations must determine whether corrective action includes individual coder education, broader policy or training updates, or in the case of significant overpayments, a required refund to the payer.
Overpayment Refund Obligations
Under the Affordable Care Act, organizations that identify an overpayment generally must report and return it within a specified timeframe, making timely audit-driven identification of overpayments a compliance necessity rather than an optional best practice.
Exam Tips
Expect questions on the different audit types, appropriate sampling methodologies, and the organization's obligations once a coding-related overpayment has been identified through the audit process.