A written audit report including title page including “confidential – attorney-client privilege – do not reproduce. Table of contents and the following sections:
– General Findings & Recommendations
– Specific Findings and Recommendations
– Follow-up (refunds, education etc.)
Background: As a health information professional, it is essential that you are able to audit the quality of ICD 10 CM coding. This exercise will introduce you to the world of coding audits.
*OIG Model Compliance Plan for Hospitals: https://oig.hhs.gov/authorities/docs/cpghosp.pdf
*How to Choose the Right Coding Audit Method, AHIMA BoK: https://bok.ahima.org/doc?oid=302442#.XQ0XUYhKi70
*Best Practices in Coding Audits: https://www.fortherecordmag.com/archives/0118p10.shtml
Learning Objectives: After completing of this exercise the student will be able to:
Audit for coding accuracy
Evaluate coding accuracy
Summarize the findings, including developing a list of recommendations for improvement.