Maintaining Quality in Financially-Focused Audit Denial Prevention

By Shimeka Johnson, MSHCM, RHIA, CHPS, CCS, CDIP, CPB, CPCO, CPC-P, CPMA, CPPM, CRCR

Imagine: you’ve just had the most successful month of the year. No coding backlogs, pre-bill audits all completed in a timely fashion, clinical documentation improvement (CDI) staff have checked off the monthly quota for physician education sessions, and hospital management staff are very happy with the expected revenue from operations. But then, four weeks later, a different view approaches on the horizon: insurance denials, requests for medical record documentation, and health information management (HIM) staff calling emergency meetings to discuss the looming fight ahead to capture much earned revenue.

You may be asking yourself, are the medical records complete? Do we have the required documentation to support the billed charges? Did the physicians really buy into the CDI educational classes? Do we have a gap in coding quality? Did the CDI staff miss something? Wait a minute, didn’t we have coding updates recently?

This is a scenario that many hospital HIM departments face monthly—walking the thin line of ensuring adequate revenue is generated from submitted claims while maintaining quality during coding and pre-bill auditing.

Some very important quality-focused concerns include second level reviews, hospital-acquired conditions (HACs), and present on admission (POA) status.

The goal of second level reviews is to prevent claims denials to ensure final coding and DRG assignment is accurate prior to billing and severity of illness and risk of mortality are reflected in the documentation. This is a concurrent process between the CDI and coding taff to verify appropriate coding before billing and a great opportunity to identify areas of improvement and education for the entire team, including physicians.

Hospitals are not paid additional reimbursement for conditions that are acquired during the hospital stay. The POA status is used to determine which conditions were present at the time of admission. POA is defined as a condition present at the time of admission. These can develop in an outpatient encounter such as an outpatient surgery, in observation, or in the emergency department. It is applicable to principal and secondary diagnosis. Documentation must clearly support the POA status, or a query must be created for documentation clarification.

Shimeka Johnson (shimekajohnson@yahoo.com) is an HIM consultant, AHIMA-approved ICD-10-CM/PCS trainer, and AHIMA ICD-10 Ambassador.