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
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
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
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
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
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
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,”
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.
10. Educate physicians on providing
complete, clear and concise documentation. “Review entities are starting to focus