The Power and Value of Auditing for Revenue Loss Prevention

Auditing has many proven benefits for providers. Audits can help identify gaps, inconsistencies, and areas of risk not previously seen. In particular, weaknesses in charge capture of drug administration services and overlooked revenue opportunities are key reasons for putting together an audit practice. Historically, many professionals have defaulted to billing edits to catch issues with drug administration codes submitted on the claim, but this is far from enough to protect against problems. Let’s take a look at the must-haves to ensure a healthy preventative audit process.

Knowledge Requirements

Those staff responsible for charge entry, coding, charge reconciliation, and auditing must learn and maintain an excellent understanding of the following:

  • drug administration coding hierarchy
  • determination of units
  • applicable dates of service
  • modifier requirements
  • NCCI edits
  • and medical record documentation requirements.

Creating a knowledgeable team is only the first step. The team must have the capacity to tackle the results of the periodic audits, communicate the results, and provide additional staff education when needed. The audit team (or individual, depending on size of provider staff) will need to agree on the minimum audit requirements. There are several key components needed for an appropriate audit sheet. The audit worksheet should include fields for:

  • patient account
  • drug administration codes billed
  • units reported
  • date of service
  • start and stop time
  • staff responsible for generation of charges
  • staff responsible for reconciliation of charges
  • financial impact (if any), and
  • review comments.

So, what are other tips for creating a useful audit sheet? The audit worksheet needs to be:

  • easy to complete
  • easy to read
  • and useful in effectively communicating issues

Note that the audit schedule should be congruent with the frequency of billing drug administration services. Understand that normally providers set a quarterly schedule to review a set number of encounters, and then increase review frequency when issues or opportunities are identified.

Post Audit Debrief and Communications

So how should staff tackle post-audit education? Post-audit education can be tracked through more frequent reviews until the provider is satisfied that staff retention merits return to the normal audit schedule. Professionals should not underestimate utilizing consistent review frequency. Doing so is important since turnover of knowledgeable staff has impacts on coding and billing. Many providers turn to external vendors with the expertise in drug administration coding and billing needed to satisfy internal audit policies and procedures.

Documenting the audit and communicating the results effectively is an important step to take in the audit process. Know that clear concise communication of the results is necessary. This is especially important where the financial impact is significant such as in areas involved in overcoding or undercoding.

It is key to have an open discussion of the results with staff involved in charge capture and charge reconciliation (coding) and with nurses responsible for documentation. Note that the number of findings often is associated with nursing documentation. Bringing together all these individuals to discuss results and corrective actions can reduce misunderstanding of what and why process improvements are needed while fostering an informative, collaborative, and aware environment.

It is best for the audit team to retain copies of reviews to identify patterns over time. Understand that patterns may include a staff member (or coder) who is struggling with application of the coding hierarchy. Another example of potential pattern is a nurse who is consistently failing to document stop times for infusion services. Once patterns are identified, the audit team should take additional steps to educate and train staff. This action helps to create certainty that competency checks guarantee coding and documentation are appropriate for billing drug administration services.

Education for drug administration coding is available through a variety of resources including our own books and webinars, along with external vendors. Education provides extensive information on coding hierarchy and documentation requirements. Providers should take this need into consideration when budgeting for the audit team.

Understand that if your organization has engaged a third-party service to either code or bill for infusion services be certain to review guidance published by the Office of Inspector General (OIG) for third-party billing arrangements and perform periodic compliance audits.

These are not all the tips and knowledge necessary for successfully mastering infusion and injection services. Overcome more everyday challenges and find further educational insights by utilizing our Coding Essentials for Infusion & Injection Therapy Services.


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