Best Practices of a Coding and Documentation Audit


Although the term “audit” often elicits dread in a company, for medical coding operations, auditing can ensure that your coding process is accurate and efficient — which is good news for revenue cycle management.


Medical coding is a complicated process but a vital one to ensure proper documentation, compliance, and revenue cycle management for healthcare facilities. A periodic medical coding audit will ensure the accuracy and efficiency of your coding practices to maximize revenue and reimbursements. Here’s what you need to know about coding and documentation audits.

The importance of a coding and documentation audit

Although conducting a coding audit may sound uncomfortable or even intimidating, the benefits of conducting one and the consequences of not doing so can significantly affect your revenue cycle. An audit can evaluate your overall coding and transaction processes and determine whether they are functioning properly. It can identify areas of lost revenue due to poorly documented service.

An audit can also help you ensure the accuracy of your coding, evaluate the necessity of medical services, and discover lost revenue due to poorly documented services. It will help you protect against fraudulent claims and correct problem areas before payers challenge reimbursement claims. You can also use the results of an audit to educate staff on the importance of accurate records.

Audit best practices

Before beginning your audit, set up your processes and guidelines for conducting it. Determine how large of a sample you’ll study and whether it will cover all payers or a specific payer. Determine what exactly you’ll be auditing. For example, will you be looking at a particular coder or provider, specific diagnoses, or selected surgical cases? Also, you’ll want to establish your coding standards. The gold standard is 95% accuracy.

To ensure compliance, check areas with high compliance risk. Also, make sure coders are up to date with constantly changing CPT, ICD-10, and HCPCS code sets.

 An audit is simply a tool to discover weaknesses as well as strengths in your coding and documentation processes so you can make appropriate adjustments.

Pros and cons of using an internal auditor vs. an outsourced auditor

Choosing between an internal or external audit doesn’t mean that one is better than the other. They each have their strengths, and you’ll likely use them both at various times to help improve your processes. An internal audit will require a qualified staff member familiar with not only coding practices but also the auditing process and should be conducted quarterly. Internal audits will help determine whether what was billed and what was documented are in accord with each other.

External audits can objectively analyze operations and uncover deficiencies that an internal audit may miss. An external audit also helps strengthen future internal audits by discovering how and why internal audits may have overlooked findings.

TruBridge not only provides top-quality coding services for healthcare facilities but also can provide professional auditing services. Our customized auditing solutions can determine any inefficiencies or accuracy problems in your coding operations and provide advice for improving and streamlining them in order to improve your revenue cycle. Get in touch with our expert team to find out how we can streamline your auditing process.

Written by Stacey Sexton
TruBridge Vice President, Health Information Services

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