The Purpose of Coding Compliance Auditing
Coding compliance auditing verifies that codes assigned to patient encounters accurately reflect documented clinical conditions and services, supporting both accurate reimbursement and adherence to official coding guidelines and payer policy. A well-designed auditing program reduces compliance risk while identifying opportunities for coder education.
Types of Coding Audits
Audits vary in scope and purpose. Baseline audits establish an initial accuracy benchmark, often performed when a new coding compliance program is established. Focused audits target specific high-risk areas identified through data analysis, denial trends, or OIG Work Plan priorities. Random audits sample across all coding activity to provide a general accuracy picture. New employee audits closely monitor recently hired coders during an onboarding period before transitioning to standard audit frequency.
Audit Scope Considerations
- Inpatient versus outpatient coding
- Specific DRGs, CPT codes, or service lines
- Individual coder performance versus department-wide trends
- Pre-bill versus post-bill timing
Sample Selection
Sample selection methodology affects the validity and usefulness of audit findings. Random sampling provides a statistically representative view of overall accuracy, while targeted sampling focused on high-dollar claims, complex DRGs, or previously flagged issues maximizes the compliance value of limited audit resources. Sample size should be large enough to yield statistically meaningful results, commonly a minimum of 20 to 30 records per coder or focus area.
Findings Documentation
Audit findings should be documented in a standardized format capturing the original code assignment, the auditor's recommended code, the discrepancy type, and a clear rationale referencing applicable coding guidelines. Clear documentation supports coder education, tracks trends over time, and provides a defensible record in the event of external audit or investigation.
Corrective Action Plans
When audits reveal significant accuracy deficiencies, a formal corrective action plan should outline specific remediation steps, responsible parties, and timelines. Corrective actions may include individualized coder education, department-wide training on identified error patterns, revised coding workflows or query templates, or increased audit frequency until accuracy improves to acceptable levels.
Linking Audits to OIG Compliance Expectations
Regular, documented coding audits demonstrate a functioning compliance program consistent with OIG Compliance Program Guidance, and can mitigate penalties if improper billing is later discovered, since a robust auditing history demonstrates good-faith compliance efforts rather than willful disregard.