Self-auditing Programs Help Ensure Proper APC Assignment

By now, you probably know that the quality of your coders will drive the quantity of your Medicare reimbursement when ambulatory payment classifications (APCs) become effective. But how do you know your coders are getting it right? Mary Zupko, coding quality and compliance manager for the medical records department at the Hospital of the University of Pennsylvania, advises setting up a comprehensive audit program. Any time youre dealing with coded data for billing purposes, you really need an internal auditing program to ensure the accuracy of the coding, she says.

Caral Edelberg, CPC, CCS-P, president of Medical Management Resources Inc., an emergency department coding consulting firm in Jacksonville, Fla., calls auditing essential for identifying payment problems quickly and providing feedback to coders about errors. In todays hospital billing office, it is not uncommon to see payments and denials simply entered without using the process to identify problems and communicate them to the departments responsible for addressing them on the front end.

According to most estimates, hospitals will lose more than 5 percent of their Medicare revenue under APCs, and the new codes promise to complicate the billing process. Because theyre changing the way outpatient procedures are being paid, there will be implications about how the patients are registered, Zupko says. Most hospitals are increasing their outpatient services. More patients, less payment per patient. Its going to affect the bottom line, so youre going to have to make sure youre coding correctly.

As hospitals will now be required to code the facility levels with a more objective criteria based on the physician CPT and HCPCS evaluation and management (E/M) levels, there must be an understanding of how these codes are used, Edelberg says. There is still some interpretation necessary due to the absence of clear guidelines, particularly when interpreting the medical decision-making component of the physician E/M level. This will be uncharted territory for most hospital medical records departments, so a lot of work needs to be done to ensure that coding is neither too conservative nor too liberal.

Who and When to Audit

Unfortunately, coders really shouldnt audit themselves, Edelberg says. It usually takes someone else to shed new light and new perspective on issues.

To ensure the accuracy of her employers coding, Zupko and her staff do audits at the end of the day, every day. One benefit is that youre correcting the data before it drops onto the bill.

Such a self-policing program benefits the hospital in two ways, she says:

1. Quality Control. Zupko requires her coders to maintain a 98 percent accuracy rate. On a daily basis, we can identify problems before they become systemic.

2. Compliance. The self-auditing program helps Zupkos employer meet requirements set down by the Office of the Inspector General (OIG) [...]

- Published on 2000-05-01