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Internal auditing strategies for ongoing ICD-10 success

Internal auditing strategies for ongoing ICD-10 success

Editor’s note: This article was modified from HCPro’s latest long-term care title, ICD-10 Compliance: Process Improvement and Maintenance for Long-Term Care, written by Maureen McCarthy, BS, RN, RAC-MT, and Kristin Breese, BSN, BSed, RN, RAC-MT. The complete book helps facilitate ongoing ICD-10 success by arming SNF readers with information and strategies that target the preparation, implementation, and maintenance phases of the fast-approaching coding transition. For more information or to order, call customer service at 800-650-6787 or visit


With the October 1 implementation date of ICD-10 now on a fast track to fruition?and no further delays in sight?even the most committed holdouts in the provider community have kicked off initiatives to ensure staff, outside business partners, and workflows can withstand the major coding transition.

To ensure that preparations made over the past months (or years) ultimately pay off, SNFs should start laying the groundwork for regular facility-wide audits of ICD-10 systems in the aftermath of implementation?a proactive approach that can help providers verify the strength of ongoing transition efforts and catch any snags before they disrupt essential facility processes.

Thus, although the word "audit" can provoke fear and anxiety in providers?often connoting scrutiny and penalties when administered by Medicare contractors?facilities can head off these unsavory external audits, or at the very least reduce negative outcomes, by conducting their own internal varieties.

In a broader sense, frequent self-audits can promote overall business vitality by facilitating the development and maintenance of sustainable processes across the facility, particularly in the face of the impending overhaul to coding methodology and practice.


The scope of self-audits

The Office of Inspector General (OIG) considers ongoing monitoring and evaluation important elements of a healthcare organization’s compliance program and identifies two overarching types of reviews:

1.Standards and procedures reviews, which measure whether internal standards are current and complete, or are in need of an update to reflect regulatory changes

2.Claims submission audits, which gauge whether coding, billing, and documentation are in compliance with payer and government contractors, as well as whether services performed are reasonable and support medical necessity

The OIG states that self-audits, which generally fall into the second category of reviews, can accomplish an array of verification processes. More specifically, the agency explains that these audits can be used to determine whether:

  • Bills are accurately coded and reflect services provided
  • Documentation is complete and correct
  • Services or items provided are reasonable and necessary
  • Any incentives for unnecessary services exist

The baseline audit

SNFs should launch a baseline audit after the first three months of ICD-10 implementation. This initial evaluation will help providers identify areas that need improvement or education. To shape baseline (and subsequent) audits, facilities should consider the following list, which identifies key aspects of major operational areas the ICD-10 transition is likely to affect:


2.Coding/billing in the electronic health record system



5.Strategic considerations


Subsequent audits

Once SNFs have completed their baseline audits, they should analyze the outcomes to develop an auditing compliance plan, which can function as staffs’ blueprint for future documentation, coding, and billing.

The ICD-10 task force, or transition team, should appoint a post-ICD-10 committee to review initial implementation results, evaluate success against established criteria, and identify what works and doesn’t work, especially in the revenue cycle, health information management, and IT realms.

Prior to the October 1 kickoff, this committee should determine which measures will be tracked and collect related preliminary data.

Following the go-live date, this committee?and the facility at large?must be on the lookout for significant post-implementation issues, including claims denials and rejections or coding backlogs. The committee must quickly identify such issues, create feedback loops, and follow the established solution path to remediation?a task that’s best facilitated by routine auditing of both claims and supportive documentation in a patient’s medical record.

Facilities should track all ICD-10 submissions and receipts for 3?6 months after the transition. Quality assurance monitoring should focus on ensuring proper receipt of ICD-10 codes by vendors and payers. Providers should also be sure to address all communications from these sources, as well as trading partners and CMS.


Key takeaways

Routine review of ICD-10 coding will soon become an essential function of all facilities’ quality monitoring systems and resulting performance improvement plans. Auditing documentation for sufficient data to support specificity in ICD-10 diagnosis coding should begin 2?3 months prior to the transition and continue well after October 1. Conducting ongoing auditing is crucial to update or solidify processes that underlie, facilitate, and support ICD-10 coding and claim submission, thereby ensuring a hassle-free conversion to the new system. – Billing Alert for Long-Term Care