Medical billing requires precise coding.
Medical coding of rendered services requires attention to detail to ensure a truthful health claim for insurance payments. A coding compliance program uses audit trails to keep track of changes made to medical codes.
Identification
An audit trail is simply the organization of information in a sequential manner. Any changes or adjustments to medical codes referring to a patient's care requires documentation from beginning to end. Coding compliance programs help medical coders stay within the industry's guidelines for fair coding and billing.
Features
An audit trail is maintained by keeping the coding within a timeline. The medical coding software allows users to view all original coding posts. Then, if there are changes to the original coding numbers, the adjustment is viewable right beside the original codes. The viewable changes, as well as a detailed explanation of the adjustments, allows a clear view of the medical coder's reasoning process for the code adjustment. The final, billed coding numbers are shown in the end of the coding software record, completing the audit trail.
Significance
A medical facility can trace any problematic employees by viewing the sequence of coding changes. Performance standards become visible through coding adjustments, such as missed diagnoses.
Tags: audit trail, coding numbers, coding software, medical codes, original coding