AHIMA Advantage - August 2011

In addition, organizations should understand how their EHR speaks to the auditor. “You want the EHR to say the same thing as your paper record does,” said Easterling. “But it’s going to say it a little differently. For example, in the paper world, a nurses’ note may have included a freehand synopsis. However in most EHR systems, there are only drop down boxes or fields to click. And the question is, “Can she adequately express the patient’s condition with those boxes or fields?”

All about Audits

Here are 20 ways you can help your organization handle audits more successfully.

Responding to Audits

1. Train staff to recognize audit letters. Establish procedures to manage incoming requests and work on them immediately.

2. Study up on the auditor. Identify who is auditing your organization, and look for that auditor’s hot spots. The AHIMA Communities of Practice, such as Recovery Audit Contractor, Coding, and Coding Hospital Inpatient, are a good source of information.

with mounds of electronic documents, advised Easterling. Arrange the record chronologically so it reads like a book (especially important for medical necessity cases). “I want my record to show how sick my patient was when he presented to my admitting doctor and what happened in those initial hours to justify an inpatient admission,” she explained. Call attention to critical pieces of documentation with tabs and underlining.

4. Check completeness. “If the physician hasn’t dictated the discharge summary yet, I’ll ask the physician to dictate so I can mail the record off,” said Easterling. Documentation should support the services billed, including key pieces like labs or radiology exams.

5. Keep vendors accountable. “If you work with an external vendor to copy records, make sure they meet deadlines. I’ve seen the process fall apart there,” said Wilson.

6. Make a paper trail. “Send audit
documentation certified mail with a
return receipt, FedEx, or some other way
that ensures you have a receipt, so the
auditor can’t come back and say, you
missed the deadline—which could result
in a technical denial and dollar recoup-
ment of the entire stay,” said Wilson.

Setting up Ongoing Policies
and Processes

7. Develop a tracking tool for following the status of each audit. “Tracking is one of our biggest challenges. We have a home-grown, Web-based system that helps us manage the process. That’s a huge key,” said Easterling.

8. Monitor data quality continually. Don’t wait for an audit to flag your data. Perform internal and external coding and documentation audits and pre-bill reviews. “Target DRGs that the RAC has been known to review, such as respiratory failure records and excisional debridements,” said Maccariella-Hafey.

9. Tap HIM expertise. Review denials with coding staff related to coding or DRGs. If there are issues with coding, have HIM professionals, handle those letters. Consider setting up a dedicated audit response position staffed by an HIM professional.