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JACS Cancer Hospital HIM 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
Audit Results of Records 159 Total Records Audited 13 Records with Deficiencies
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
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:Documentation Standards
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.