In an internal coding audit review program, which risk area is prioritized for auditing?

The prioritization of the Chargemaster description and medical necessity in an internal coding audit review program is significant because it directly impacts the financial and compliance aspects of healthcare facilities. The Chargemaster serves as the comprehensive listing of items billable to a hospital or healthcare facility. A well-maintained Chargemaster ensures that services are accurately coded and billed according to regulations.

Auditing the Chargemaster helps identify discrepancies between what services were provided (and documented) versus what is being billed, which is crucial for compliance with reimbursement regulations. Medical necessity is also critical, as services provided must be justified as necessary for patient care according to established clinical guidelines. If claims fail to reflect medical necessity, healthcare providers risk denials from payers and potential legal consequences for fraudulent billing.

Focusing on this area for audits helps organizations minimize financial risk, improve billing accuracy, and comply with healthcare regulations, thereby protecting their revenue cycle. This systematic approach to auditing supports the integrity of financial operations while safeguarding against compliance issues.