A written audit report including title page including “confidential – attorney-client privilege – do not reproduce. Table of contents and the following sections:

– Background

– Scope

– Sample

– 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.

References

*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.