Presented by: Mandy Reid, MS, RHIA, CPC, Dir of Clinical Coding & … · 2020-05-14 · Professional Audit Scope and Methodology • Engaged Optum360 to perform a coding and clinical

Professional Coding & Documentation Enhancement Project

Presented by: Mandy Reid, MS, RHIA, CPC, Dir of Clinical Coding & CDI Lisa A. Walter, RHIA, Vice President, HIM Consulting

Proprietary and Confidential. Do not distribute.

Project Goals

Scope and Methodology

Findings and Recommendations

Next Steps

Questions & Answers

Agenda

3

4 Proprietary and Confidential. Do not distribute.

Project Goals

• Increase accuracy of coding and billing for appropriate payment • Minimize billing errors and avoid audits to minimize compliance risk • Focus on Professional clinical documentation improvement • Provide education to Providers and Coders • Identify opportunities for improvement in CDI, Coding and electronic

documentation


Professional Audit Scope and Methodology

• Engaged Optum360 to perform a coding and clinical documentation audit of: – 2050 medical encounters – 1050 surgical encounters – 520 primary care medical encounters (50 providers)

• Audit of E/M, CPT , ICD diagnosis and clinical documentation

improvement opportunities

• Provided Surgical and Primary Care provider reports

• Customized Specialty and Primary Care education onsite

• Shared Provider and Specialty E/M bell curve data

• Data was pre ICD-10 diagnosis coding

Medical/Surgical Audit Summary


Audit Results

• Identified top E/M practice area opportunities

• Identified top CPT practice area opportunities

• Provided detailed audit findings to Providers

• Customized education for each specialty area, presented onsite

Audit Results

Specialty Bell Curve Data

E/M Documentation Guidelines

Modifiers and their selection

Q&A

Provider Education Agenda

8


Professional Coding Summary Results – Medical or Surgical

• Optum360 performed a CPT & E/M coding and documentation review for Specialty, encompassing the review of approximately 10 records per provider

Below is a sample coding accuracy rate for the physicians

Code Accuracy Rates

Total Codes Number of Coding Issues Accuracy Rate

CPT/HCPCS 2 0 100%

E/M Coding 212 62 70.75%

Case Action Summary Case Action # of Records % of Total

Documentation Issue 4 1.9%

E/M Code Issue 62 30.0%

No Issue Noted 141 68.1%


Medical/Surgical Findings & Recommendations

• History

• Proper Surgical Assist documentation

• Shared/Split services documentation

• Consult documentation – MD’s vs NPP

• Proper modifier usage

Primary Care Audit Summary


Selected HCC Medical Conditions Acute vs. Chronic conditions

Congestive Heart Failure

DVT Klebsiella Pneumoniae

Risk Factors and Comorbidities

Angina COPD Epilepsy & Convulsions

Myocardial Infraction

Septicemia & Sepsis

Artificial Openings Cor Pulmonale GERD

Neoplasm Ulcers & Wounds

BMI and Obesity CVA Hepatitis & Cirrhosis Neuropathy Varicose Veins

Cardiac Conduction Disorders

Dementia

HIV

Pneumonia Vertebral Fractures

Cardiomyopathy Depression Hypercholesterolemia

Pulmonary Embolism

CKD, Dialysis, and an AV Fistula

Diabetes and Secondary Conditions

Hypertension

Pulmonary Hypertension

Complications of Care Differential Diagnosis

Hypothyroidism

Respirator/ Ventilator Status


Diagnosis Coding Results

25

217

520

0 20 40 60 80 100

Revise

Delete

Add

Number of ICD-9 Codes

11


Primary Care Findings and Recommendations

• Just One Point Notes

1. Clinical documentation does not support diagnoses codes billed • Example: Tobacco use

2. Causal relationship not clearly documented

3. Link medication to the diagnosis

4. Document status V/Z codes and chronic conditions • Example: Hypertension

• BMI status and weight category

• Smoking Cessation

• Advance Care Planning

• Annual wellness


Optum360 Consulting - HIM Consulting Services

Optum360 Consulting - Expertise and Resources

Revenue cycle • Assessment & Business Process Transformation

• Revenue Integrity Optimization

• CDM evaluation and maintenance

• Charge Accuracy & Pricing Analytics

• Denial Intelligence

• Interim placement of revenue cycle leadership roles

Shared Services • Assessment & Planning

• Remediation Strategy & Planning

• Testing Design & Management

• Education (eLearning & instructor-led)

• Compliance monitoring & ongoing improvement

• KPI dashboard design & monitoring

• HIM, CDI & Revenue Cycle Integration

• Communication & Change Management

Health Information Management • Operational excellence assessment & business

process transformation

• Optum CAC readiness assessment & CAC optimization review

• Interim placement of HIM/Coding management roles

• ICD-10-CM/PCS coding quality reviews & education

• CPT/HCPCS and E&M coding and clinical documentation quality reviews and education

• HCC Risk Adjustment reviews & education

• HIM Operations Wellness Assessment

Clinical Documentation • Baseline analytics & documentation reviews

• Operations & Infrastructure Transformation

• Education for practicing physicians, nurses , CDI Specialists, other (Video & instructor-led)

• Ongoing monitoring programs

Education & Project

Management

Documents

Presented by: Mandy Reid, MS, RHIA, CPC, Dir of Clinical Coding & … · 2020-05-14 · Professional Audit Scope and Methodology • Engaged Optum360 to perform a coding and clinical