Audit and Compliance

Audit and Compliance

Audit and Compliance – What’s it all about ..Audit and Compliance – What’s it all about ..

• Audit is defined as: an official examination and verification of accounts and records, especially of financial accounts.

• Compliance is defined as: a state in which someone or something is in accordance with established guidelines, specifications, or legislation …

• So what does this mean for HIM professionals…• We need to perform our duties while adhering

to established guidelines and specifications as laid our by our governing bodies ..

• State … Federal.. And Association

ComplianceCompliance• Following established Federal Guidelines: UHDDS• Uniform Hospital Discharge Data Set• The UHDDS definitions are used by acute care short-term

hospitals to report inpatient data elements in a standardized manner. These data elements and their definitions can be found in the July 31, 1985, Federal Register (Vol. 50, No, 147), pp. 31038-40.

• There are a total of 42 possible elements of a UHDDS form. First are basic demographic elements, such as age, gender, ethnicity, marital status and education levels. Another set has to do with the hospital or health facility, including patient numbering systems, type of facility and assigned doctor or nurse. Finally, complete information about the reason for the patient coming to the hospital is recorded, including self-reported diagnosis, physician diagnosis, services rendered by the facility and dates of all procedures.

UHDDS Definitions UHDDS Definitions

Inpatient diagnoses and procedures shall be coded in accordance with Uniform Hospital Discharge Data Set (UHDDS) definitions for principal and additional diagnoses and procedures as specified in the Official Guidelines for Coding and Reporting.

•The principal diagnosis is defined in the UHDDS as, “that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.”

Selection of Principal DiagnosisSelection of Principal Diagnosis

CODES FOR SYMPTOMS,SIGNS, AND ILL-DEFINED CONDITIONS •Codes for symptoms,signs and ill-defined conditions from Chapter 16 are not to be used as a principal diagnosis when a related definitive diagnosis has been established.

TWO -OR- MORE INTERRELATED CONDITIONS, EACH POTENTIALLY MEETING THE DEFINITION FOR PRINCIPAL DIAGNOSIS •When there are two or more interrelated conditions (such as a disease in the same ICD-9chapter manifestations characteristically associated with a certain disease) potentially meeting the definition of principal diagnosis, either condition may be sequenced first, unless the circumstances of the admission, the therapy provided, the Tabular List, or the Alphabetic Index indicate otherwise.


TWO OR MORE DIAGNOSIS THAT EQUALLY MEET THE DEFINITION FOR PRINCIPAL DIAGNOSIS. •In the unusual instance when two or more diagnoses equally meet the criteria for principal diagnosis as determined by the circumstances of admission, diagnostic workup and/or therapy provided, and the Alphabetic Index, Tabular List, or another coding guideline does not provide sequencing direction, any one of the diagnoses may be sequenced first.


COMPARATIVE -OR- CONTRASTING CONDITIONS. •In those rare instances when two or more contrasting or comparative diagnoses are documented as "either/or" (or similar terminology), they are coded as if the diagnoses were confirmed and the diagnoses are sequenced according to the circumstances of the admission. If no further determination can be made as to which diagnosis should be principal, either diagnosis may be sequenced first. SYMPTOMS(s) FOLLOWED BY CONTRASTING/COMPARATIVE DIAGNOSIS. •When a symptom(s) is followed by contrasting/comparative diagnoses, the symptom code is sequenced first. All the contrasting/comparative diagnoses should be coded as additional diagnoses.


ORIGINAL TREATMENT PLAN "NOT" CARRIED OUT. •Sequence as the principal diagnosis the condition, which after study occasioned the admission to the hospital, even though treatment may not have been carried out due to unforeseen circumstances.

COMPLICATIONS OF SURGERY AND OTHER MEDICAL CARE. •When the admission is for treatment of a complication resulting from surgery or other medical care, the complication code is sequenced as the principal diagnosis. If the complication is classified to the 996-999 series and the code lacks the necessary specificity in describing the complication, an additional code for the specific complication should be assigned.


UNCERTAIN DIAGNOSIS •If the diagnosis documented at the time of discharge is qualified as "probable", "suspected", "likely", "questionable", "possible", or "still to be ruled our", or other similar terms indicating uncertainty, code the condition as if it existed or was established.

NOTE: This guideline is applicable only to inpatient admissions to short term, acute, long-term care and psychiatric hospitals.


ADMISSION FROM OBSERVATION UNIT

1. Admission Following Medical Observation

When a patient is admitted to an observation unit for a medical condition, which either worsens or does not improve, and is subsequently admitted as an inpatient of the same hospital for this same medical condition, the principal diagnosis would be the medical condition which led to the hospital admission.

2. Admission Following Post-Operative Observation

When a patient is admitted to an observation unit to "monitor" a condition (or complication) that develops following outpatient surgery, and then is subsequently admitted as an inpatient of the same hospital, hospitals should apply the Uniform Hospital Discharge Data Set (UHDDS) definition of principal diagnosis as :that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care."


ADMISSION FROM OUTPATIENT SURGERY •When a patient receives surgery in the hospital's outpatient surgery department and is subsequently admitted for continuing inpatient care at the same hospital, the following guidelines should be followed in selecting the principal diagnosis for the impatient admission.•If the reason for the inpatient admission is a complication, assign the complication as the principal diagnosis.•If no complication, or other condition, is documented as the reason for the inpatient admission, assign the reason for the outpatient surgery as the principal diagnosis. •If the reason for the inpatient admission is another condition unrelated to the surgery, assign the unrelated condition a s the principal diagnosis.

REPORTING ADDITIONAL DIAGNOSISREPORTING ADDITIONAL DIAGNOSIS• For reporting purposes the definition for :other diagnoses: is interpreted as additional

conditions that affect patient care in terms of requiring:

clinical evaluation; ortherapeutic treatment; ordiagnostic procedures; orextended length of hospital stay. orincreased nursing care and/or monitoring.

The UHDDS defines "other diagnosis" as "all conditions that coexist at the time of admission, that develop subsequently, or that affect the treatment received an/or the length of stay. Diagnosis that relate to an earlier episode which have no bearing on the current hospital stay are to be excluded." UHDDS definitions apply to inpatients in acute care, short-term, long term care and psychiatric hospital setting. The UHDDS definitions are used by acute care short-term hospitals to report impatient data elements in a standard manner.

REPORTING ADDITIONAL DIAGNOSES REPORTING ADDITIONAL DIAGNOSES

The following guidelines are to be applied in designating :there diagnoses when neither the Alphabetic Index nor the Tabular List in the ICD-9-CM provide direction. The listing of the diagnosis in the patient record is the responsibility of the attending provider.

A. Previous condition

If the provider has included a diagnosis in the final diagnostic statement, such as the discharge summary or the face sheet, it should ordinarily be coded. Some providers include in the diagnostic statement resolved conditions or diagnoses and status-post procedures from previous admission that have no bearing on the current stay. Such conditions are not to be reported and are coded only if required by hospital policy.

However, history codes (V10-19) may be used as secondary codes if the historical condition or family history has an impact on current care or influences treatment.

ABNORMAL FINDINGSABNORMAL FINDINGS

Abnormal findings (laboratory, x-ray,pathologic, and other diagnostic results) are not coded an reported unless the provider indicates their clinical significance. If the findings are outside the normal range and the attending provider has ordered other tests to evaluate the condition or prescribed treatment, it is appropriate to ask the provider whether the abnormal finding should be added.

UNCERTAIN DIAGNOSISUNCERTAIN DIAGNOSIS

• If the diagnosis documented at the time of discharge is qualified as "probable", "suspected", "likely", "questionable", "possible", or "still to be ruled out" or other similar terms indicating uncertainty, code the condition as ...IF IT EXISTED -OR- WAS ESTABLISHED.

NOTE: This guideline is only applicable to inpatient admissions to short-term, acute, long-term care, and psychiatric hospitals.

Procedures:Procedures:

In accordance with UHDDS definitions, all significant procedures are to be reported.

– A significant procedure is one that is (1) surgical in nature, or (2) carries a procedural risk, or (3) carries an anesthetic risk, or (4) requires specialized training.

– When more than one procedure is reported, the principal procedure is to be designated. In determining which of several procedures is principal, the following criteria apply:

• The principal procedure is one that was performed for definitive treatment rather than one performed for diagnostic or exploratory purposes, or was necessary to take care of a complication.

• If there appears to be two procedures that are principal, then the one most related to the principal diagnosis should be selected as the principal procedure.

UHDDS Definitions - continuedUHDDS Definitions - continued

• Reportable Diagnoses/Procedures. To achieve consistency in the coding of diagnoses and procedures, all individuals who are authorized to perform coding/claims processing of inpatient services (“Coding Personnel”) must:

– Thoroughly review the entire medical record as part of the coding process in order to assign and report the most appropriate codes.

– Adhere to all official coding guidelines as approved by AHA, AHIMA, CMS and NCHS (“Cooperating Parties”).

– Observe sequencing rules identified by Cooperating Parties.

– Assign and report codes, without physician consultation/query, for diagnoses and procedures that are not listed in the physician’s final diagnostic statement only if those diagnoses and procedures are specifically documented in the body of the medical record by a physician directly participating in the care of the patient, and this documentation is clear and consistent;

UHDDS Definitions - continuedUHDDS Definitions - continued

• Reportable Diagnoses/Procedures

• Areas of the medical record which contain acceptable physician documentation to support code assignment include the discharge summary, history and physical, emergency room record, physician progress notes, physician orders, physician consultations, operative reports, physician notations of intraoperative occurrences and other ancillary, diagnostic reports signed by physicians (such as anesthesia report, pathology report)

• When diagnoses or procedures are stated in other medical record documentation by non-physicians (nurses notes, MDS abstract (SNUs), pathology report, radiology reports, laboratory reports, EKGs, nutritional evaluation and other ancillary reports), the attending physician must be queried for confirmation of the condition. These conditions must also meet the coding and reporting guidelines outlined in AHA Coding Clinic, 2Q, 1990 page 12.

UHDDS Definitions - continuedUHDDS Definitions - continued• Reportable Diagnoses/Procedures• Utilize medical record documentation to provide specificity in coding, such as

utilizing the radiology report to confirm the fracture site or referring to the EKG to identify the location of an MI.

• Consult the physician for clarification when conflicting or ambiguous documentation is present. Ask the physician to add information to the record before assigning a code that is not supported by documentation

Query ProcessQuery Process

• Coding Personnel should query the physician once a diagnosis or procedure has been determined to meet the guidelines for reporting but has not been clearly or completely stated within the medical record by a physician participating in the care of the patient or when ambiguous or conflicting documentation is present.

• All facilities should educate their physicians on the importance of concurrent documentation within the body of the medical record to support complete, accurate and consistent coding.

Query ProcessQuery Process

• Communication should be provided to the medical staff that individuals responsible for coding patient diagnoses or procedures will query physicians when there are questions regarding documentation for code assignment. The physician’s response to the query should be signed by the physician and become part of the medical record. The facility itself should determine if the actual coding query will be maintained as part of the medical record.

• Coding Personnel must not suggest a code or medical record documentation that is not supported by the patient’s clinical presentation and/or condition. Coding Personnel may relate to physicians what the particular documentation requirements are for specific codes, and the physician can then make the appropriate documentation decision based upon the patient’s clinical presentation and/or condition.

Data Quality ApplicationData Quality Application

• Coding Personnel must not: – Add diagnosis codes solely based on test results, unless diagnosis is

obtained from physician through the query process.– Misrepresent the patient’s clinical picture through incorrect coding or

adding diagnosis/procedures unsupported by the documentation for any reason.

– Report diagnoses and procedures that the physician has specifically indicated he/she does not support.

Facility Coding Reviews – Audit findingsFacility Coding Reviews – Audit findings• Internal (or external) coding quality reviews must be completed on a regular

basis by each facility.

• Reviews should include review of the medical record to determine accurate code assignment with subsequent comparison with the UB-04 claim form to determine accurate billing.

• Findings from these reviews must be utilized to improve coding and medical record documentation practices and for Coding Personnel and physician education, as appropriate.

Questions …..Questions …..

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Audit and Compliance