The Need for Accurate Records and Medical Coding Audits
Medical coding audits verify and complete records of the documents related to the patient’s treatment and procedures followed by the hospital. And this medical record is assigned a code that is known by every medical coder and the hospital staff which makes it easy to understand for the hospital staff and the private health insurance companies who are going to reimburse for the medical expenses. This medical record is also used by the hospitals, internally, to conduct the administrative and research activities. Data that is so beneficial for the hospital and insurance companies should be completed, correct and authenticated. For this purpose, medical coding auditing is required for medical records coding.
Medical coding audits are related, basically, with the verification of the records containing the history of the patient, and by finding that the records are maintained with accuracy and that they are not wrong. Medical auditing deals with the various aspects related with the medical coding process. The auditors are required to find out that the medical coder is following all the rules and regulations for coding by the American Medical Association; or whether or not they comply with AMA standards.
The auditors are also responsible for the quality of maintaining the medical records by the coder and find out that they are completely trustworthy. The main objective of performing the auditing on the medical records is that they should communicate accurately the actual results and findings of the treatment provided to the patient. These details are considered by various government departments for research and to find out the history of the disease. It is also important for declaring any diseases as epidemic or not.
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Professional Auditors Determine Coding Compliance
Now days various auditing agencies are in the market that provide assistance with the audit process of medical records. These agencies verify various records related to inpatient services, outpatient services, physician facility and other services. These agencies provide the expert auditor’s team who are qualified and capable of doing the auditing for small practices and clinics, as well as the larger size hospitals. The auditors of the agencies also provide training to the coders of the healthcare providers; this can help them to improve their quality of coding. When the auditing is complete, the auditors will provide detail of their findings and suggest any corrections to medical coders, as they are responsible for detecting the errors in the coding process.
Medical coding audits are very beneficial for improving the quality of work of the healthcare providers, and it gives an accurate picture of billing compliance to auditors and to insurance companies.
However, audits can be done by the physician on their own, by following the rules and regulations of the auditors, and then taking any corrective measures for the errors.