JACS Cancer HospitalHIM Project Improvement Team

Julie Callahan, Ashley Diebler, Casey Wilson, Sabrina Chapman

Mission Statement

• To evaluate the current organizational coding processes to determine improvement measures and to initiate a compliance plan that will ensure our healthcare professionals, clients, third-party payers, and other stakeholders are provided with the most accurate and complete billing, as well as data collection/storage/retrieval services.

Vision

• To be the region’s leader in accurate and complete health information management services, who upholds the highest ethical and legal standards, by following all HIPAA and state laws.

Values

• Accuracy

• Comprehensiveness

• Consistency

• Accessibility

• Currency

• Definition

• Granularity

• Precision

• Relevancy

• Timeliness

• Ethicality

Goals

• Establish ongoing monitoring to identify problems or opportunities to improve quality of coded data

• Make recommendations for improvement in the Coding Compliance Plan

• Optimize the coding process• Identify variations in coding practices among staff members• Determine cause and scope of identified problems• Set priorities for resolving identified problems• Implement mechanisms for problem-solving through approval of

corrective action plans• Ensure that corrective action is taken by following up on problems with

appropriate monitors• Ensure compliance while meeting organizational needs• Assess for quality health information management & risk management• Decrease over-utilization for healthcare services• Use a database management software application to demonstrate the

use of database technology for collection storage and retrieval of healthcare data to support ongoing quality assessment

Customers/Stakeholders and Customers’ Requirements

• Healthcare professionals

• Patients

• Third-party payers

• Registries

• Administration

Provide the most up-to-date and accurate codes for health records. In order to submit claims that provide the most appropriate reimbursement.

Quality Assessment

• Audited 30 patient health records with previous code assignments to ensure all codes were up-to-date, correctly assigned, and that no codes were missing.

Quality Assessment Tools

• Brainstorming

• Check sheets

• Emails

• Discussion boards

• Graphs

• Excel spreadsheets

• PowerPoint

Quality Improvement Measures

• Coding accuracy classified as:

– Correct

– Wrong

– Missing

– Extra

Compiled Data Spreadsheet

Type of Coding System Used526 Total Codes

ICD-9 Diagnoses Codes Audit Results (321 Total Codes)

ICD-9 Procedure CodesAudit Results (31 Total Codes)

CPT Procedure CodesAudit Results (42 Total Codes)

CPT Pathology CodesAudit Results (43 Total Codes)

CPT E/M CodesAudit Results (89 total Codes)

Total Number of Codes Audit Results

74.90%

8.37%

15.78%

0.95%

Correct (394)

Wrong (44)

Missing (83)

Extra (5)

(526 total)

Audit Results of Records

159 Total Records Audited 13 Records with Deficiencies

Correct Codes by Coding System

Wrong Codes by Coding System

Missing Codes by Coding System

88%

4%4%

2% 2%

(83 total)

ICD-9 Diagnosis (73)

CPT E/M (3)

CPT Procedure (3)

CPT Pathology (2)

ICD-9 Procedure (2)

Extra Codes by Coding System

Recommendation for Improvement

•Coding Compliance Plan•Policies and procedures related to:

– Documentation Standards– Documentation Guidelines– Resources all coders should have– Internal audit process– Physician query process– Education and training– Identify risk areas related to coding– Corrective Action– Reporting of compliance issues

Quality Improvement Measure:Documentation Standards

• Accuracy• Comprehensiveness• Consistency• Accessibility• Currency• Definition• Granularity• Precision• Relevancy• Timeliness• Legibility• Authenticity• Approved format• Policies/procedures

• Record should be organized systematically

• Only authorized individuals should document, receive, and transcribe

• Authors should be clearly identified

• Use only approved abbreviations/symbols

• All entries should be permanent

• Errors should be corrected in appropriate fashion

• Use addendums to correct or add info.

• Training/education• Structured data in EHR

Quality Improvement Measure:Resources for Coders

• AHIMA’s Standards of Ethical Coding• CMS and AHIMA’s Official Coding Guidelines &

requirements• Facility-based coding guidelines• Any state-specific requirements• Website access to LCDs and NCDs• Updated code books• NCCI edits• Coding Clinics• CPT Assistant• A medical dictionary• A pharmacology reference• An anatomy/physiology reference

Quality Improvement Measure:Internal Audit Process

• Internal audits conducted weekly• If 10% or greater of submitted claims get denied conduct

internal audits daily until % of denial is 5%– HIM coding manager or supervisor will perform internal

audits using claim analysis checklist• Random selection of 5 records per coder will be audited• Random selection of 10 records per federal payer and 5

records per physician will be audited• All trends and coding errors analyzed to determine reason for

coding errors• Audit results presented to coding staff, supervisors, physicians,

and corporate compliance officer• Coders to maintain accuracy of 100% or greater

– Below 100% subject for review and/or corrective action• Revisions to policies/procedures and systems edits; additional

education/training; disciplinary action

Quality Improvement Measure:Query Process

• Query when documentation fails to meet the following criteria regarding any significant reportable condition/procedure:– Legibility– Completeness– Clarity– Consistency– Precision– **Do NOT question a provider’s clinical judgment

• Query should include all appropriate information according to form• Query should follow facility-approved query form• Query should be in a timely manner whether concurrent, retrospective,

post-bill design, or a combination of the three• Providers response is required within 48 hrs. Consequences for

noncompliance• Providers response documented in progress note, discharge summary,

or query as part of the formal health record.

Quality Improvement Measure:Education and Training

• Provided for– Physicians– Coders– Clinical documentation specialists– Other ancillary departments (Case management, wound care, laboratory,

nutrition, etc.)

• Form:– Webinars: provide reliable, expert, and timely information– Audio seminars– Online education– In-class

• Topics:– AHIMA– ICD-10-CM– EHR Implementation– American Recovery & Reinvestment Act of 2008– Recovery Audit Contractors (RACs)

Quality Improvement Measure:Risk Areas Related to Coding Issues

• Only bill for items/services actually rendered• DO NOT upcode to enhance reimbursement• DO NOT unbundle to enhance reimbursement• DO NOT bill for discharge when a transfer occurred• DO NOT bill for outpatient services rendered with

inpatient stays if follows 72-hr window rule• DO NOT assign codes resulting in DRG with higher

payment if not supported by documentation (DRG Creep)• DO NOT make code selection on radiology, laboratory, or

any other diagnostic test result• ALWAYS follow coding guidelines unless payer specifies

otherwise in writing and are approved by HIM manager• ALWAYS read ALL clinical documentation• ALWAYS query physician when documentation is unclear

Quality Improvement Measure:Corrective Action

• Corrective actions for resolving problems identified during coding audits include:– Revisions to policies and procedures– Process improvements– Education of coders, physicians, and/or

organizational staff depending on the nature of the identified problem

– Revision or addition of routine monitoring activities

– Revisions to the chargemaster– Additions, deletions, or revisions to systems edits– Documentation of improvement strategies– Disciplinary action

Quality Improvement Measure:Reporting of Coding Compliance Issues

• All employees are required to promptly report any good faith belief of a violation of the laws and regulations that govern JACS Cancer Hospital

• No employee will suffer any penalty or retribution for reporting in good faith any suspected misconduct or noncompliance

• Any employee who fails to report knowingly suspected misconduct or noncompliance may be subject to disciplinary action

• Any employee who purposely makes a knowingly false accusation will be subject to appropriate discipline

• Compliance concerns may be reported to the department supervisor, manager, or compliance officer either orally or written

• Individuals may also report anonymously at the JACS hotline which is open 24 hours a day and 7 days a week

• All reports will be referred to the compliance department

Benefits of Coding Compliance Plan

• Improved coding accuracy

• Decrease in denials

• Improved physician documentation

• Relevant physician and coder education

• Proactive research into variations from benchmark data and their underlying causes

• Timely identification, correction, and prevention of potential coding compliance risks

References

• Johns, M. L. (2011). Health information management technology: An applied approach. (3rd ed.). Chicago, IL: AHIMA.

• Schraffenberger, L. (2012). Basic ICD-10-CM/PCS and ICD-9-CM coding. Chicago, IL: AHIMA.

• Schraffenberger, L. A. & Kuehn, L. (2011). Effective management of coding services. (4th ed.). Chicago, IL: AHIMA.

• Shaw, P. L. & Elliott, C. (2012). Quality and performance improvement in healthcare: A tool for programmed learning. (5th ed.). Chicago, IL: AHIMA.

• Smith, G.I. (2012). Basic current procedural terminology and HCPCS coding. Chicago, IL: AHIMA.