You work for Happyville Health System as the Health Information Management (HIM) Director.

You work for Happyville Health System as the Health Information Management (HIM) Director. You are working with the Coding Supervisor to develop a one-page coding audit that will be utilized when auditing coding specialists’ work. The one-page coding audit will also be integrated into the organization’s coding compliance program.

INSTRUCTIONS

First, create a one-page coding audit template that is well-organized, and each section has appropriate headings and functional areas for documentation and collection of information during the audit.

The template should include the following:

The section at the beginning of the template should be to collect and document the staff member’s information (ex. first/last name, employee number), the auditor’s name, the date of the audit, and data related to the chart that was audited (ex. episode number, date of service).

The body of the template should be split into ICD-10-CM, CPT/HCPCS, and ICD-10-PCS sections.

Within the three sections, there should be areas for noting the codes assigned by the coding specialist and the codes assigned to the auditor.

Each of the three sections should have a comment area for the auditor to add notes or additional information.

The section at the end of the template should be to conclude the audit, with an area for a determination of approval, additional training, etc.

Next, develop a one-page procedure document for using the one-page coding audit template that:

Describes the process for completing the audit using the one-page coding audit template and how it fits into the coding compliance plan.

Summarizes how the one-page coding audit template will improve the coding compliance plan’s effectiveness in appropriate reimbursement.

General Requirements

Uses correct spelling, grammar, and punctuation in the one-page coding audit template and one-page procedure document.