Implementing a Revitalized Coding and Documentation Program
Establishing consistent processes for coding and documentation review is fundamental, but our approach to provider education and training is the key driver of meaningful improvement.
While working with a hospital physician enterprise to improve operationally, we were asked to address coding and documentation issues for clinical patient encounters, including all provider types and specialties.
The primary objective was to establish an accurate and consistently approved audit process. Provider documentation varied, making it difficult to evaluate process and establish consistency. Decision-making assessments were subjective and also varied greatly by provider.
As an external and independent expert, we completed the coding solutions process, entailing an initial assessment, ongoing audits, follow-up education, and recurring analyses to ensure long-term compliance. We worked as an extension of our client's team to help ease their stress and implement a sustainably compliant system.
Approach
- Step 1Initial Analysis
Analyze trends and tendencies to discover the best audit approach. - Step 2Provider Coding Audits
Complete initial assessment to determine accuracy and compliance. - Step 3Scorecard Report
Provide a summary of findings and recommendations. - Step 4Ensuring Success
Host a follow-up review with providers to ensure successful work. - Step 5Additional Audits
Provide recurring audits at least every six months to sustain success.
Regular audits, training, and continual compliance monitoring were adopted for the entire physician enterprise, resulting in regular coding audits. Coker provided a specialized team of coding experts who provided everything from general coding expertise to more specialized procedural and surgical coding audits. We reviewed and made every effort to ensure compliance plan adherence.