What Are the Different Types of Medical Reviews? How to Choose the Right Type for Your Healthcare Facility

What Are the Different Types of Medical Reviews? How to Choose the Right Type for Your Healthcare Facility

Medical coding audits, or medical reviews, are one of the most crucial tools in maintaining compliance and accuracy in the healthcare industry. They ensure your organization’s coding practices align with current regulations, prevent financial penalties, and optimize reimbursement processes. However, with various types of audits available, healthcare providers may find it challenging to determine which audit best suits their specific needs.

At YES HIM Consulting, we offer a comprehensive range of medical reviews tailored to meet the diverse needs of health systems, hospitals, physician clinics, and other healthcare providers. In this article, I explore the various types of audits we can provide and how you can make an informed choice to select the right type for your facility.

Overview of Medical Reviews Offered by YES

We recognize that different healthcare organizations have unique challenges and goals. To address these distinct needs, we offer a suite of medical coding audits designed to ensure accuracy, compliance, and efficiency across various coding processes.

Compliance Audits

Compliance audits are essential for maintaining regulatory adherence and minimizing the risk of financial penalties. These audits involve a thorough review of coding practices across Inpatient, Outpatient, and Professional Fee settings. Our compliance audits focus on key areas such as DRG validation, modifier usage, discharge status, and place of service codes. For Outpatient and ProFee settings, we examine CPT modifiers, E/M levels, APCs, and surgery coding.

The primary goal of compliance audits is to identify any discrepancies or areas of non-compliance that could lead to reimbursement issues or regulatory scrutiny. We provide detailed trending reports and coder review sheets with recommendations for corrective actions backed by relevant coding resources and references. Our clients can customize the trending reports to focus on specific data points or time periods.

Reimbursement Audits

Reimbursement audits, often conducted as part of a compliance audit, focus on post-bill audits to identify opportunities for rebilling miscoded services. The audit results will pinpoint cases that are overcoded, undercoded, and correctly coded. If services are overcoded, we provide recommendations to the facility to make the necessary corrections. It is the facility’s responsibility to enact those changes and rebill those services in order to avoid potential penalties and legal actions. If services are undercoded, our reports will display the reimbursement changes after rebilling is performed. It is up to the facility to rebill those services in order to earn the correct reimbursement for the services performed. These audits can directly impact a facility’s revenue cycle. Additionally, the audit reports provide educational opportunities for the coders to assist with their ongoing education and training, which will decrease future financial losses.

Secondary/Mentoring Reviews

Secondary reviews, or mentoring reviews, are particularly beneficial for facilities onboarding new coders or recent graduates. These audits are conducted on a pre-bill basis, allowing the facility to develop strong coders who can efficiently handle various coding settings. We provide daily feedback on coded cases and hold weekly meetings with auditors and facility supervisors to review progress and address any concerns.

This mentoring approach ensures that new coders quickly become productive team members while maintaining high accuracy and compliance standards.

Due Diligence Audits (DDA)

Due diligence audits (DDA) are designed for companies acquiring or merging with a medical practice. These coding audits assess the accuracy of diagnosis coding, E/M levels, and RVUs, providing insights into the practice’s financial performance and potential liabilities. We offer recommendations on how the practice can improve coding accuracy and compliance, which is crucial for both coders and physician-entered coding.

To learn more about our DDA services, download our “Healthcare Mergers & Acquisitions (M&A) eBook,” which offers a comprehensive guide to navigating these complex audits and the M&A process as a whole.

Provider Documentation Audits

Provider documentation audits focus on reviewing clinical documentation to ensure that it supports the selected codes. They also identify educational opportunities for providers, helping them improve their documentation practices to better reflect the complexity of patient care. Accurate documentation is critical for proper coding and billing, and our audits help bridge the gap between clinical care and coding accuracy.

Specialized Audits

Specialized audits are tailored to review specific procedures or diagnoses. These audits are ideal for healthcare providers that offer niche services or have recently introduced new service lines. Our specialized audits ensure that coding practices align with the latest guidelines and that all billable services are accurately captured.

Deciding Which Type of Audit Is Most Appropriate

Selecting the correct type of audit depends on several factors, including the organization’s current needs, staffing levels, and any specific questions or concerns related to coding or reimbursement. Additionally, internal compliance departments often play a key role in determining the most suitable audit. However, external audits from a trusted partner like YES can provide valuable insights and support if resources are limited.

Healthcare organizations should consider whether they have the capacity to conduct internal audits or if they need external assistance. Our audit results can be used to evaluate coder performance, tie into quality improvement initiatives, and identify areas where additional training may be required.

Factors to Consider When Selecting an Audit Focus

When choosing an audit type, healthcare organizations should consider the following factors:

• Current Coding Challenges: Are there specific coding issues or concerns that need to be addressed? This could include questions about E/M levels, modifier usage, or DRG validation.
• Staffing Levels: Does your organization have the internal resources to conduct audits, or would external support be beneficial?
• Education Needs: Is there a need to educate providers or coders? Our audits provide insights in creating custom learning journeys through our online Learning Management System (LMS) to address any knowledge gaps identified during the audit process. Additionally, as part of all our audits, we can give clients access to a weekly question queue where their team can ask our auditors for advice about a scenario.

Adapting to Emerging Trends in Medical Reviews

One emerging trend is the introduction of new technologies and services into the healthcare industry. As new medical devices and procedures enter the field, so do new methods of capturing and coding those trends. Additionally, the ongoing updates to coding guidelines, such as the ICD-10-CM/PCS and CPT codes, require continuous education and adaptation.

To stay ahead of any industry trends, our firm invests in the continuous education of our staff and clients. We keep up with new data sets and coding updates, ensuring our auditors are equipped with the latest knowledge and tools. Our goal is to help healthcare facilities adapt to new service lines, surgeries, and procedures while maintaining compliance and accuracy in coding.

Avoid These Common Mistakes When Preparing for an Audit

Preparation is critical for a successful audit, and there are several common mistakes that healthcare organizations should avoid:

• Unrealistic Expectations: Audits take time, and it’s important to manage expectations regarding timelines and outcomes. Specialized training prior to the audit can help set realistic goals.
• Disorganized Data: Successful, streamlined audits require organized and accessible data. We offer standardized documentation templates to help streamline this process.
• Lack of Communication: Open communication with auditors is essential for a successful audit. Organizations should ensure that they are transparent and cooperative throughout the audit process.

The Importance of Choosing the Right Medical Review & Audit Partner

Medical coding audits are an essential tool for healthcare providers to ensure compliance, accuracy, and financial health. By selecting the correct type of audit and working with a trusted partner like YES, healthcare organizations can address their specific needs, improve coding practices, and streamline their revenue cycle.

We offer a range of auditing services tailored to meet the diverse needs of the healthcare industry. Whether you’re looking to validate your coding practices, onboard new coders, or optimize reimbursement, our experienced coding consultants and auditors are here to help. Schedule a quick consultation today to learn more about how our audits can benefit your organization.