In this episode, we’re pleased to welcome back Kristen Eglintine, BESLER’s Coding Manager of Revenue Integrity Services, to give us a glimpse into BESLER’s next webinar, The Differences Between Pre and Post Auditing that we’re hosting on Wednesday, November 1st at 1 PM ET.Learn how to listen to The Hospital Finance Podcast® on your mobile device.
Highlights of this episode include:
- Differences between pre-bill and post-bill auditing overview
- What is the importance of inpatient auditing?
- Examples of an inpatient audit
- Common findings
- Best practices
Kelly Wisness: Hi, this is Kelly Wisness. Welcome back to the award-winning Hospital Finance Podcast. We’re pleased to welcome back Kristen Eglintine, BESLER’s Coding Manager of Revenue Integrity Services. In this episode, Kristen will give us a glimpse into BESLER’s next webinar, The Differences Between Pre and Post Auditing that we’re hosting on Wednesday, November 1st at 1:00 p.m. Eastern Time. Thank you for joining us today, Kristen.
Kristen Eglintine: Hello, Kelly. Hi, everyone. I am very happy to be joining again. This is going to be a great webinar, and I’m happy to be sharing some information about it.
Kelly: Awesome, well, let’s go ahead and jump in, shall we? So, we know we have an upcoming webinar on the differences between pre-bill and post-bill auditing. Can you give us an overview of what we can expect?
Kristen: Pre-bill and post-bill auditing is a topic close to my heart as I do a lot of it. I’m excited to share all this good information we have. There are many types of healthcare audits out there from internal audits which are conducted by the internal auditors of a hospital’s own staff, such as a quality officer. There are clinical audits that focus on quality improvement. However, for this discussion and webinar, I’m going to be referring to external inpatient medical coding audits. The agenda for the upcoming webinar is packed full of pre-bill and post-bill auditing information. That includes we’ll start with an overview of inpatient auditing, which is defined as a process that involves an official examination, a validation of the medical record documentation, and coding in the inpatient setting. It usually involves reviewing reimbursement, quality, and coding accuracy. And then to get a little deeper, for reimbursement, an inpatient audit involves review and validation of the principal diagnosis, the CCs and/or MCCs that are reported, and procedures that may affect the DRG for appropriate payment. We’ll touch briefly on the difference between an inpatient and an outpatient audit. From there, we’ll go into documentation and what to look for in an auditor.
So, if you are looking to hire someone to do an audit, what are the qualifications you want? What are their credentials? Are they familiar with national and state reporting guidelines and programs? Do they have experience? So those are a few things that you would put on your hit list of what I want in an auditor. We’ll talk about the scope of an audit. This is generally a statement that specifies the focus, the extent of the audit. It would lay out the timeline and the volume of a particular audit. You would touch on patient class and the payer. Is this a Medicare-only audit or is it Medicare, Medicaid, or perhaps commercial? You would also then dial in the focus of the audit. Whether this is an MSDRG audit or an APR DRG, you would define the findings. There are some standard findings that are used in audit reports such as opportunity and compliance and error or variance. We want to make sure that you and your client agree on the definition of the findings prior to the audit. That’s an important step. From documentation, we’ll move into the industry challenges and compliance issues that are out there. We’ll give you the pros and cons of the pre-bill versus a post-bill audit. And then we’ll end the webinar with a bunch of case examples and an audit conclusion.
Kelly: Wow, thank you for that overview, Kristen. So, what is the difference between a pre-bill and post-bill audit?
Kristen: A pre-bill audit is a review of medical codes assigned to a patient’s medical record before the bill is generated. These pre-bill audits; they are used to help identify and correct coding errors or discrepancies that may lead to a claim denial or just even a payment delay. A post-bill audit is a retrospective review and analysis of the medical codes assigned to a patient’s medical record. And this is done after a claim has been submitted. This can be done with the intent of issuing a rebill if an error was found or for educational reasons only.
Kelly: Thank you for that explanation. So, what is the importance of inpatient auditing?
Kristen: So, there are so many good things that can come out of an audit. Audits prevent errors. They identify them. They apply the corrective actions to them. They can reduce costs. They improve your compliance to all sorts of regulations, whether they just be the hospitals or state or federal. They enhance patient experiences. They help protect against fraudulent claims and billing. They can help you assess your risks and identify common problematic areas that need attention. They can compare performance from your organization with national averages. So, you can see if you’re on trend with everyone else with the same sort of hospital population. They do improve overall operational efficiencies. They can correct outdated templates or policies that you may have in place. So there’s so many different things that come out of an audit, all good and definitely worth doing.
Kelly: Very interesting. Can you give us a couple of examples of an inpatient audit?
Kristen: So, this would be where you are discussing with the client about the scope. So, you could do like a full claim audit where you’re going line by line, comparing the details to the medical records, to claims. You could just do a DRG audit, whether that just be an MS or an APR. There’s HCC validation audits. So here the audit would focus on HCCs, which are chronic conditions that the patient would have, though a few acute conditions do qualify, to ensure that they have been documented correctly and submitted on the claim form appropriately. You could do an inpatient audit for missed opportunities. Is there something that was documented and wasn’t reported on the claims so missed monies for the organization? You could focus more on the coder side. So, it could be more of a staffing audit. So, do you have new coders? Was there a lot of turnover? Do you have contract coders? And do you need to compare your coders versus contract coders? And then more in the outpatient world, but you could do physician-focused audits. So, there’s so many different ways you could approach an inpatient audit.
One type that you often hear about is a compliance audit. Compliance audits are a necessity for all healthcare organizations as they gauge how well an organization adheres to rules and regulations and even internal bylaws and codes of conduct. Compliance audits help identify compliance issues, such as no supporting or just a lack of documentation for a code that’s been reported. They identify medically unnecessary services, leading and/or non-compliant queries. They help identify where you apply your own interpretation of clinical indicators versus querying the provider. So, the coder may be making some clinical judgments that they shouldn’t be, therefore reporting codes that aren’t supposed to be on the claim. Compliance audits also identify billing for services that were not rendered. So, the compliance audit is a very popular one to do for an inpatient setting.
Kelly: Very interesting. So, what are some common findings in an inpatient audit?
Kristen: I would say two common themes that come up would be either undercoding or overcoding. So undercoating is when you is not accurately defining the illness burden of a patient. So, you did not report all of the clinical conditions that patient has. Whereas an overcoding is when a more complex diagnosis is reported that is not supported by the provider’s documentation. An example of that would be if you reported that a patient had sepsis, which does greatly impact reimbursement. When the patient has not met any sepsis clinical indicators or criteria, or if sepsis was ruled out by the provider, but it still gets reported on a claim. That’s an example of overcoding. And whether that’s intentional or accidental, overcoating can result in significant fines in addition to repayment of the original claim. Undercoating is not the answer in those cases to avoid accidental overcoding. I’ve seen a few times healthcare organizations swing too far the other way after an audit. So, I always say the best strategy is to accurately capture all aspects of a patient’s encounter the first time. So, there isn’t any corrective measures needed.
Kelly: That makes a lot of sense, Kristen. We can all agree that correct coding is important. What are some best practices an organization can do to stay compliant?
Kristen: So again, a lot of different things here. There’s collaboration between your coders, your CDI staff, your physician liaisons, collaboration and working together as a team, there really can make sure that your claims are reported correctly. You could do an internal second-level review, do some internal auditing of your own staff, standardizing compliant query policies and internal policies and procedures surrounding queries. Staying on top of regulatory updates is a big thing to do to stay compliant. Making sure that you review the latest coding and CDI resources, such as your ICD-10 CM and PCS guidelines that change yearly, staying current on the AHA coding clinic, hiring professional coders, making sure that they’re credentialed is another way you ensure that your organization stays compliant. Using the right resources and tools, there’s a lot of online lookup tools and software. We need to be careful of electronic codes that just populate into systems. Failing to stay current with updated coding guidelines can be a major problem for some organizations. So again, use caution with your EHRs so that codes don’t get populated that weren’t meant to be there. And that is for your integrated computer-assisted coding modules. And then, again, just be careful of the cut and pasted information from previous visits. Sometimes with these electronic health records, a lot of the information just gets cut and pasted from one chart to another or from one visit to another. And that can cause a lot of issues as well.
Kelly: Wow, we appreciate all those best practices, Kristen. And thank you so much for joining us and for sharing this sneak peek into BESLER’s upcoming webinar, The Differences Between Pre and Post Auditing that you’re presenting live on November 1st at 1:00 p.m. And as a bonus, you can earn CPE. Thanks again, Kristen.
Kristen: Thank you. And thanks everyone for spending a few minutes with me today. And just like Kelly had said, if you’d like to hear more about the pre-bill and post-bill audits, please join me on Wednesday, November 1st. I look forward to it.
Kelly: So do we. And thank you all for joining us for this episode of the Hospital Finance Podcast. Until next time…
[music] This concludes today’s episode of the Hospital Finance Podcast. For show notes and additional resources to help you protect and enhance revenue at your hospital, visit besler.com/podcasts. The Hospital Finance Podcast is a production of BESLER | SMART ABOUT REVENUE, TENACIOUS ABOUT RESULTS.
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