Level 3: Mastery & Audit Specialist

Expert Audit Methodology

Master comprehensive audit techniques and systematic compliance monitoring

Mastery-Level Objectives
  • Design and implement comprehensive audit programs that mirror MAC methodology
  • Identify systematic compliance risks through statistical analysis and pattern recognition
  • Develop effective remediation strategies with measurable outcomes
  • Create audit tools and documentation that demonstrate compliance program effectiveness
  • Assess organizational compliance culture and implement systemic improvements
Comprehensive Audit Framework
Expert-level audit design and execution methodology

1. Stratified Sampling Strategy

High-Risk Stratum (50% of sample):

  • • Top 10% CMG assignments
  • • Cases with 3+ Tier 1 comorbidities
  • • FIM scores clustering at CMG thresholds
  • • Diagnoses with high coding complexity (CHF, CKD, malnutrition)

Medium-Risk Stratum (30% of sample):

  • • Mid-range CMG assignments
  • • Cases with 1-2 Tier 1 comorbidities
  • • New coders' work (first 90 days)

Random Sample (20% of sample):

  • • Baseline accuracy assessment
  • • Detect unexpected patterns

2. Multi-Dimensional Audit Criteria

Coding Accuracy (40%)

  • • Tier assignment correctness
  • • ICD-10 code specificity
  • • Comorbidity capture completeness

Documentation Quality (40%)

  • • Physician diagnostic statements
  • • Clinical support for codes
  • • Absence of uncertain language

FIM Accuracy (15%)

  • • Scores match functional documentation
  • • Appropriate use of helper scores
  • • Consistency across disciplines

Process Compliance (5%)

  • • Timely IRF-PAI completion
  • • Query documentation
  • • Signature/authentication

3. Statistical Analysis for Pattern Detection

Key Metrics to Track:

  • • Tier 1 Rate: % of cases with Tier 1 comorbidities (compare to national benchmark)
  • • Average CMG: Facility average vs. peer group (outliers trigger MAC review)
  • • FIM Distribution: Look for clustering at threshold values
  • • Diagnosis Frequency: Sudden increases in specific codes (red flag)
  • • Coder Variance: Significant differences between coders (training need)
  • • Error Rate Trends: Improvement over time (demonstrates compliance program effectiveness)

4. Root Cause Analysis

For each identified error, determine:

  • • Knowledge Gap: Coder doesn't understand coding rule → Education
  • • Documentation Issue: Physician documentation inadequate → Query process improvement
  • • System Issue: Coding software limitation → IT solution
  • • Process Failure: Inadequate review/oversight → Workflow redesign
  • • Intentional: Deliberate upcoding → Compliance investigation

5. Audit Report Structure

Executive Summary: Overall accuracy rate, high-level findings, financial impact estimate

Methodology: Sample size, stratification approach, audit criteria

Findings: Specific errors with chart references, categorized by type and severity

Root Cause Analysis: Why errors occurred, patterns identified

Corrective Action Plan: Specific interventions with timelines and responsible parties

Reaudit Plan: When and how you'll verify effectiveness of corrections

Module Quiz
Test your knowledge of Expert Audit Methodology concepts

10

Questions

90%

Passing Score

~15

Minutes

Quiz Instructions:

  • Answer all 10 questions to complete the quiz
  • You must score 90% or higher to pass
  • You can navigate between questions before submitting
  • Review explanations for all questions after submission
  • Retake the quiz as many times as needed to pass