Coding Overview and the Commander’s Statement

August 2008

DQMC

Why this matters to Data Quality

• Coded data is used to make decisions regarding:– Population health– Funding– Anticipating the needed mix of providers – Justifying new equipment

• You need to know the quality of your data to decide how much to trust it

How this affects DQ

• This talk is mostly about – How to ensure your reported data are correct– How to do an audit that actually tells you

something

Ways to employ this info in your DQ programs

• We will discuss the most successful ways to improve your coding– Teach– Use– Audit – this includes taking action on issues

found during the audit and correcting them, permanently

Goal

• Quality data on which to base sound decisions– For you– For your Commander– For your Service– For the Military Health System (MHS)

Suggested Coding “Solution”

• Have each new provider, prior to receiving privileges to practice at your MTF, spend 4 hours with a good coding trainer– Option to “test out” of the class by passing

test composed of examples of quality documentation which the provider will enter the correct diagnoses/external causes of injury, evaluation and management code(s) with modifiers, procedure code(s) and any other applicable HCPCS code(s)

Coding Basics

• International Classification of Diseases– Diagnoses, why patients seek/receive care– Also used for inpatient institutional workload– Explains why the provider did the service

• Used to support medical necessity

• Current Procedural Terminology– Type of service furnished, office visit, x-ray– Used for professional services workload– Used for outpatient institutional workload

Coding Basics

• Codes are assigned based on documentation • Diagnosis codes are assigned differently based

on the setting (inpatient or outpatient)• Military Health System has special coding

requirements, which are logical, and are needed to accurately reflect services

http://www.tricare.mil/ocfo/bea/ubu/coding_guidelines.cfm

One-on-one Training Overview

• Each training is specific to the specialty involved (e.g., training is different for obstetrics, orthopedics and occupational therapy)

• 1 hour documentation/diagnoses• 1 hour evaluation and

management/modifiers/quantity• 1 hour procedures/supplies/training• 1 hour practice

Training Goals

• Learn basics of good documentation

• Learn basics of outpatient (not inpatient or APV) ICD/E&M/CPT/HCPCS coding

• Learn when to ask for coding assistance

• Become comfortable asking coder questions (it also gets the coder comfortable working with the provider)

Measure Success of Training

• Random audit of provider’s first week of documentation/coding and provide immediate feedback

• Random audit of provider’s first month and provide immediate feedback

• Continue to audit/provide one-on-one feedback until documentation and coding are consistently at acceptable level

Professional Staff Meeting

• Arrange to have coder auditor have maximum of 5 minutes at professional staff to review issues common to the facility

• Arrange to have coders permitted to attend professional staff – This will permit a non-threatening environment

for providers and coders to interact– Coders need continuing education too

Coder Training

• If you have AHLTA, your coder must be trained to use AHLTA– Need to know so coder can figure out why something

happens• Have periodic training on military unique issues

in UBU Coding Guidelines• Review updated ICD codes in September• Review updated CPT/HCPCS codes in

December• Recommend a goal be that coder becomes

certified – AAPC or AHIMA is fine

Use Your Data

• If you try to learn a foreign language, but don’t ever need to use it – how much effort will you put into learning the new language?

• If you get plunked down in a different country where no one speaks your language – how much effort will you put into learning the new language?

Use Your Data

• A provider wants to go to a conference to learn to treat autistic children (in Banff, Alberta in January)

• Radiology wants another fluoroscopy unit• A provider wants to go to an 8-week

dermatology course at another medical center

• A provider wants a piece of equipment to do hip replacements

01234

Quanty

Jan Feb Mar April

Month

Hip Replacements

Series1

1. What does this tell you?

Answer:

• You have ten fewer hips that need replacing in May than you did in December, if your population did not change.

• What you need to know is– DEMAND/BACKLOG, – PRODUCTION, – IS THERE IN-HOUSE CAPACITY, – COST IN-HOUSE, – COST DOWNTOWN

Graphs

• 8 points make a trend IF they reflect a changing variable

• Weekly/monthly/annual grafts do NOT indicate a trend UNLESS time is a variable

• For hip replacements TIME is NOT a variable

• Looking at DQ metrics over time do not represent at “trend”

Looking at DQ Metrics

• If there is a change – up or down– Something happened

• A change indicates you need to know what changed– A provider who understands how to code

came/left– A new coder was hired– A coder took a class and trained the

department

Ad Hoc? Does it work?Our MTF adhoc reveals different numbers than what is posted by PASBA, will continue to investigate if our ADHOC needs modificationImproving, but analytical support not available. Partnering to develop different, simpler approach focusing on prvdrs with high numbers of open encounters.Untimely documentation completion/coding. Weekly reports to providers and coders addressing backlogsADMs not crossing over from AHLTA to CHCS. Guidance has been provided to clinics to help resolve the problems.Providers need to close their encounters, coders informing providers of delinquent encounters AHLTA write-back issue ticket not accepted until 3.3 loadedThere are some staff who are non-compliant. Delinquent list is provided to Admin Officers and Ch, Clinical Services monthlyAHLTA write-back errors, Tier 3 trouble tickets on this has been submitted, AHLTA version 838.23 will possible correct this issue. April data was skewed by write back errors, encounters that were coded in ALHTA did not write back to ADM. Write back issues won't be fixed until new patches occur. A few providers do not complete encounters within 3 days. Admin staff are monitoring compliance43 clinics non-compliance w/3-day business rule. Write-back errors ADM encounters not crossing over from AHLTA to CHCS1.Will continue to monitor close  Through the use of this compliance report, department chiefs are able to target non compliance as needed.  Writeback issues with AHLTA. await AHLTA/CHCS patch if not AHLTA 3.3.

Timeliness – Your Comments

T hree providers were s truggling with completing records within the three day requirement. T raining has been provided, should see an improvement for these providers . P lan: A newly developed color-coded report that can identify records in danger of failing the 15 day AP V coding timeliness metrics was ins talled on the AP V coders P C ’s . E xpect this metric to climb as records are quickly identified and coded within the 15 day date range. We will continue to monitor this metric for improvement.Inpatient and Outpatient Coding have advised wards of the requirement to submit/return records in a timely manner (within 24 hours after discharge). Inpatient Reminder List has been revised ensuring a proactive approach to minimizing delinquent records. Implemented forwarding advanced Inpatient Record review/reminder to providers prior to Inpatient Reminder Report allowing providers an opportunity to review, sign and complete records prior to the official Delinquent Inpatient Reminder List. Visibility of Inpatient Record report is maintained by senior leadership. Respectfully request continued oversight by leadership ensuring provider compliance with completing health records in a timely manner. Patient Admin has initiated efforts to scan records to external 2.b Looked at workflow process for APVs and identified a bottleneck; nurses have been holding the APV records until the patient was contacted three times post surgery. New process will have the record turned over to Patient Administration for processing within 24 hours. This combined with personnel training should resolve our APV

Timeliness – Your Comments

2.a/b. During the training provided by the Contracted Coding Trainer, providers are reminded to properly document and sign encounters daily. In addition, the process for APVs processing is being reviewed for efficiency and the Contracted Coding Trainer will remind providers about the preparing and signing of the 2a. Reason: Some providers not completing ADM records within three business days. Health Care Operations will provide Department Heads with monthly ADM report to raise awareness.ARE YOU GOING TO SHARE THIS WITH Army and AF? 2.a - Naval Hospital x unable to meet Outpatient completed SADR within 3 days, has a POA&M to address this issue. Status of POA&M - A trouble ticket was sent to NMIMC November 07, requesting directions for pulling this information locally. A TELCON on 18 Mar 08 with NH San Diego resulted in them sending a CHCS ad hoc report enabling us to pull reports to determine who and what clinic are not meeting the 3 day completion date for SADR so we can target the providers who need training to meet the targets. As the result of a conversation with Nancy Taylor, NMIMC notified me that the report is being adjusted to meet the needs of all commands needing this info and will be 8e: IBWA Rounds Completion at 62% [+8]. Process improvement and tracking are in place to improve this metric. DQ Physician Champion is heavily involved in reminding fellow physicians to “do the right thing” when

APV records ready for pick-up?

APV process remains inconsistent. New position to consolidate A&D documentation requirements to support the Lean Six Sigma project for the ASC.MTF reports 6 of 40 encounters not meeting compliance due to delayed op reports and vacation time of coder at satellite clinic. All now completed.  APV records are not readily available for pick up. Tracking APV records are still problematic. New APV regulation is completed & will be implemented.  Provider did not complete required documents timely. List of delinquencies are provided the DCCS weekly.Vacant APV Coder position; hiring action pending. ORMA down and power outage caused transcription delays; system issues resolved; backlog eliminated.APVs converted to Inpt & not cancelled. GI APVs filed & not coded. APV report run to identify cancelled; conversheet to note if coded.Completion percentage fell below normal 95% this month due to APV coding staff being on leave. Plan to back fill position when coder on leave.

Inpatient Coding Comments

Currently we are having IBWA and Inpatient records coded by the inpatient coder. IBWA encounters are recorded in the ADM; follow the standard outpatient guidelines and thus are very difficult for an inpatient coder to code. The responsibility of coding outpatient IBWA encounters has been transferred to the outpatient coding division, effective February 2008. This audit reflects IBWA coding accuracy conducted by the Inpatient Coder. The percentage of Inpatient Professional Service Rounds encounters ICD-9 codes audited and deemed correct increased by 14% from last month’s audit/data quality statement.5c. The Inpatient Professional Service Rounds encounters ICD-9 code audited and deemed correct. Initiate the use of flash cards to improver coding accuracy. A POA&M will be developed to rectify this issue.5.g, & f. – Coder has been placed on a performance improvement plan and is scheduled to attend coding Boot Camp in July 08 to enhance coding skills and gain knowledge and skills to code to highest specificity.Question 5(a): 92% (March 2008 97%) The Lead Coder will continue to offer bi-weekly employee development sessions with the coders. She will use the training materials, both printed and audio, from AHIMA. The coders who are not able to attend the sessions will be given the training materials as well as individual assistance. The Lead Coder will use the results of the quarterly audits to determine which areas need the most reinforcement. The auditor and the Lead Coder confer with the coders when the coders have problematic coding situations. 5b-5c: Inpatient Professional (IBWA) Rounds audit. This 3-prong metric continues to improve at 93%+ accuracy. Records are coded from the patient bed side chart and manually coded into ADM. Rounds encounters were audited based on the attending documentation. One calendar day of the attending professional services during each audited hospitalization was audited from the randomly selected sample. Odd registration numbers were also audited for the first day and even registration numbers were audited for the second day. All attending professional services documented on the selected day was also audited for correct coding.

Outpatient Comments

All coding templates have been reviewed by the AHL T A S pecialis t and the C oding C ons ultant. All coding templates have been loaded and providers trained on us age. C ontinued training will be provided and coding templates periodically reviewed for accuracy. T hes e templates will be us ed by all providers . Any change Plan: Patient Administration developed a list of the most common coding errors which were presented to our ECOMS, Directorates and AHLTA Sustainment Team for dissemination to our provider community. We will HCRS has implemented a bi-weekly training plan for their external coders ensuring awareness of the DOD unique requirements for both APV and outpatient coding. HCRS has assigned NHTPs APV encounters to one (HCRS) During the April audit, five outpatient records had CPTs that were incorrect or missing; eleven had E&Ms that were too high or not needed and three records were given incorrect diagnosis codes. PLAN: The addition of another coder within the last few months should allow for increased coder-to-provider communication, which Item 7b - Two out of thirty ICD-9 code were wrong. ICD-9 25600 was used vice 25605. Coders are made aware of the errors and instructed on the proper codes to be used.6b) - Audit show that two out of 30 providers used office visit codes instead of 99499, while another provider over coded an encounter, thus significantly affecting audit percentages. Coding champion and Coding Supervisor will continue to train with the emphasis on proper use of these codes.

Outpatient Comments

6.b,c,d For outpatient encounters a feedback mechanism was put in place as of January. Contract coders will provide training in July. Expect continued improvement. 6.b.c.d. and 7.b. The Contracted Coding Trainer will emphasize with the providers the importance of proper and thorough documentation that will ensure proper ICD-9 codes, and CPT codes.6. b., c., & d –Physical Therapy CPT errors occurred as a result of not documenting time for procedures done. Occupational Therapy – incorrect documentation of time spend on TX modalities. Orthopedics – incorrect code selection of IDC-9 & CPT codes. Training will be scheduled with provider and those selecting the codes. Incorrect selections of codes in all three clinics were apparent, including all three types of codes: ICD9, E&M, and CPT codes. Some of these encounters were auto released and were not selected by a coder. This will be 7.b – The APV coder is, also, under a performance improvement plan as of June 08 and is scheduled to attend Coding Boot Camp in July 08.. The errors noted were due to incorrect code selection and have been discussed What caused this? Percentage of E&M codes deemed correct increased by 3% since last month’s audit/data What are you going to do to fix? Item 6b, 6d - Four E&M were coded wrong. Code 99211 was used and should have been 99212. 99202 was used vice 99242. Three CPT code are wrong. Two CPT were not coded should had been 0500F and Q0091, 29065 should had been 99024.Corrections to encounters are completed as a part of the coding audit process and provider education and 6. c. ICD 9 codes still do not make the 95% metric. A POA&M was submitted with timelines to bring this metric up to date. Provider education and training is based on audit outcome data. The FY 08 contract funding dollars to support BMC auditing and education and training is providing the desired outcome of improving coding quality. Diagnosis ICD coding audit results – Provider accuracy rate 90%. V code sequencing and specificity errors.

Outpatient Comments The issue remains unresolved, but improvements are seen due to increasing personalized training and adjustments to AHLTA clinical templates. 6b,6c) (1) The GS auditor/trainer worked one-on-one with selected providers for two months, and their accuracy percentages are increasing. This process will continue until all of the providers are trained individually. (2) The Contract auditor/trainer will be providing coder training. (3) Asked NME to add an accuracy compliance statement to the FY09 contract statement indicating contact coders shall maintain 95% accuracy or there will be an affect on 6.b-d: The Executive Officer, Chief of the Medical Staff and Physician Coding Champion are providing personal direction to each member of the medical staff. The coders are working one-on-one with providers.2.a. Percentage of Outpatient Encounters, other than APVs, coded within 3 business days of the encounter. Have begun running a CHCS ad hoc report for encounters coded in three days each day. Will notify clinics on non-compliance with metric and continue to monitor. Providers and nurses are unable to code telephone consults secondary to systems problems. Inordinate number of "count" telephone consults by nurses. Will work with CHCS staff and Primary Care Clinic Manager to place telephone consults by nurses in "non-count" status.6.b. Outpatient Records E & M codes correct. New mental health provider choosing E&M instead of mental health codes. Documentation supports higher/lower level.6.b: The education process is ongoing with the coders and the providers. There were 8 errors out of 96 charts. The E&M errors were New vs. Established patients, Prev Med vs. Office visit, over codes, and procedure visits.The coding staff continues to provide coding education/guidance and direct feedback to the providers on a monthly basis. Moving forward with implementation of a "Clinic Strike Team" in which a coder and AHLTA sustainment trainer visit clinics and work one-on-one with providers. The team will assist with creating templates and shortcuts in AHLTA and provide coding recommendations and guidance to improve provider satisfaction, encounter documentation and productivity. Statistics on clinic coding accuracy are reviewed weekly at the Business Plan meeting. The clinic coding accuracy statistics provided have been beneficial to both the coding

Outpatient Comments

The AHLTA trainers and the medical coders have been tasked to work together to develop user friendly templates to capture all clinical treatment/procedures within the clinic. This effort will start with the surgeons and post op Subpar numbers in the coding audits have been addressed with the remote coding contract. Performance standards have been added to the FY 09 contract. The Coding trainer was on island and provided training for the physicians listed on the audit. Also, providers will be given the audit results as a training tool. Coding accuracy should increase in the May DQ statement. EXAMPLES for you to train. 6b. E&M ERRORS: Pt coded as NEW pt but documentation does not state this (4 encounters). Pt documented as NEW pt but coded as ESTablished (1 pt). Modifier 25 (unplanned procedure) needs to be added to E&M code on which unplanned procedures were performed at time of visit (4 encounters). 5 encounters coded as post-operative but global period cannot be determined because of unclear documentation. EXAMPLES continued. 6c. ICD9 ERRORS: Documentation states that the encounter is a “Pre-op” encounter therefore should be coded as primary procedure (2 encounters). Documentation states “pre-op” but diagnostic code not reported (1 encounter). Documentation states “no evidence of infection” but coded as infection (1 6 & 7. A decreas ing trend has been obs erved a in coding quality. C oding has been identified as a critical initiative in the command bus ines s plan and continues to be a top priority. T he following s teps have been taken in an a. A s enior coder has been hired and has replaced the previous G S -9 Medical R ecords Adminis trator. T he pos ition will have full-time coding and provider education and training as primary functions of the pos ition.b. C ontract coding has been increas ed.c. Data Quality is being addres s ed weekly as part of the B us ines s P lanning Workgroup—attended by B us ines s Managers , P roviders , and Adminis trators .

Outpatient Comments

d. Healthcare B us ines s O perations D irectorate has been tas ked with aggregating the audit findings to as s is t the providers in identifying trends and areas for improvement. T his data will be pres ented to the B oard of D irectors monthly as part of the Data Quality report and quarterly to the medical s taff.e. A reques t for modification to the coding contract has been approved to increas e training. S ix training ses s ions f. S T I auditor / trainer and NH R ota’s senior coder are working with our providers to improve their coding accuracy. A summary report is provided after the audit to facilitate corrective actions . g. T he s enior coder will review 100% of all AP V’s coded by the production coder and will train as required to Noted DRG and ICD.9 errors which was relayed back to the coders for correction.Coding feedback and training (based on the audited records) were given back to the providers. This is done on a monthly basis by the Coding Auditor. 7b & 7c: Slight decrease in APV audits. Coding feedback and training (based on the audited records) were given back to the coder for correction and resubmission.

Why are DD 2569 and PATCATs important?

Can You Beat This?Wilford Hall Medical Center UBO

COLLECTED $4.2M in May 2008.This includes TPCP,

MSA, and MAC.

This is $$$ for your MTFT he Deputy C omptroller and the B us iness O ffice have developed a committee to review opportunities for improvement in collection of the 2569 forms . T he B us iness O ffice also has been added as a member of the C ommand's C linical Management Ass is t DQ T eam and will provide guidance and compliance is sues for each clinic reviewed.O ngoing training is provided on O HI collection to all key areas throughout the hospital. T his process will be continually monitored. Addition to P O AM- Implemented surprise clinic specific audits for compliance and release audit results to clinic department heads . O HI DD-2569 (Apr – 100% /Mar – 37% ): T he new electronic DD-2569 which is part of our new Insurance Verification E ligibility S ys tem (IVE S ) was implemented and our metric has improved dramatically.T he DD 2659s were completed; however, not current within 12 months 2569s . Monthly random audit verification of DD F orm 2569s in health record(s ) from outpatient and ancillary clinics to be performed, documenting results with the expectation of receiving full support and corrective action from O utpatient C linic Managers , Ancillary C linics , F ront Desk C lerk(s ) and E mergency Department.6e. During the audit nine outpatient records out of 30 were missing an updated DD2569 resulting in a 70% metric. Even though this metric is below the 96% goal, NHB continues to be the top MTFs for outpatient collections for the Navy Medicine West Region. PLAN: The Business Office continues to track the number of DD2569s that are submitted each month (YTD April 2007= 9,061; April 2008=15,101) an increase of 40%. 7d. During the audit four Ambulatory Procedure records were missing the DD2569 resulting in an 80% metric. PLAN: Data Quality is working with the Department Head from Ambulatory Procedure Unit to identify the cause for the missing forms.6.e,f & 7.d Measures have been taken to ensure that all patients other than active duty personnel have a current 2569 available for auditing and billing purposes. For outpatient and APV visits the numbers are stagnating. The 2569 collection process was delegated by the ESC to DFA for recommendations and action; expect improvement in June DQ statement.

This is $$$ for your MTF

6.e & 7d - DD Form 2569 in medical records. Third Party Collections still provides monthly training per a training schedule and uses the locally created report to monitor and report compliance back to the directors and clinic managers. A new automated DD2569 in CHCS has been implemented and a contractor has been placed at the front desk of the satellite pharmacy to collect insurance information from those not otherwise seen in our facilities. In addition, the Comptroller has instituted a monetary incentive for the clinics that increase their collection of DD2569s. As a result of all the processes in place, collections of the OHI has continued to increase as result. We have increased our percentage of OHI in medical records 30%in the outpatient audits and by6.e. Outpatient Records completed and current DD Form 2569s are available for audit. TPC personnel are making rounds for collection of 2569s and to provide education to clinic staff twice per week. They are informing Department Heads of their findings. This has been in place for two months. 7% decrease over last month. Will evaluate need for change in process in Aug (Jun 08) DQ Statement.6.e: Percentage of DD2569 Third Party Collection Program/MSA/OHI forms incomplete and/or not currently signed annually. Outpatient records staff will continue to provide new DD2569 forms on the records pulled for appointments on the pull list. Training has been increased at the clinical level on how important the 2569 is and the policy that dictates its usage. Have implemented a tracking compliance metric which will help with further training requirements. The printing of the 2569's from CHCS has been implemented which will increase the accuracy of TPC information in CHCS. We should see a sharp increase in compliance starting in June. The TPC staff will be visiting each clinic every day to pick up the forms. For the Branch Health Clinics, The forms can be faxed, sent by guard mail, or hand delivered.Question 7 (d): 84% (March 2008, 94%). Only one of the Third Party Forms could not be located. Four forms were not dated and could not be counted as complete for the audit. This information was passed to the Ambulatory Procedure Department

This is $$$ for your MTF

6e)The facility will conduct more in house training with front desk personnel.6a-6d: Midshipmen visits were audited for Physical Therapy and Flight Medicine. Much better audit. E&M codes were 94%, ICD-9 codes were 91% and CPT were 88% (that should be better, but will work with providers and outside auditor for CPT coding training).6.e.) DD Form 2569: We are continuing to seek initiatives to increase overall 2569 collections. The Command recently implemented 2569 verification cards for patients, which should help positively impact this metric.What are you going to do to fix? Item 6e, 6f - Ten out of thirty does not have current DD2569. Thirteen is current and verified in CHCS. A Lean six-sigma study is underway to evaluate our process.

This is $$$ for your MTF2569s are not properly completed. Create signs, re-educate staff and develop smart book for clinicsMultiple forms missing in audit. Beta test for web-enabled DD2569 database has begun; LSS project ongoing. Rate rose to 70% – 70/100 records had 2569. New 2569 audit database & LRMC SOP finalized and in use. Personnel loss, relocation. Working with ERMC tiger team in SHIFT 1 and 2 software programs, and continuing current emphasis/education. Clinic personnel are failing to insure completion of DD Form 2569’s and forwarding to PAD adequately. Further training will be providedClinics not ensuring the form is filled out or current. TPCP clerk provides training at clinics not meeting the compliance requirementMRT clerks are not acquiring a completed DD Form 2569 on each patient when patient arrives for their appointment, training is ongoing2569s missing/not updated, turnover in front desk staff continues to be issue. Continue to educate front desk staff on importance of updating.Significant improvement over the previous report month (20% increase). Issue will be discussed at the next Managed Care meetingWe continue to strive to improve OHI capture and have fielded an electronic DD 2569 capability.DD2569 files moved to Treasurer to cut down on misplaced forms. TPC increase from $597K in FY06 to projected $1.2M in FY08

This is $$$ for your MTFWe continue to review numerous records that have missing/not completed 2569s.  Continue to train and educate clerks and admin staff. Clinics are not asking the patient to complete DD-2569.Every non-AD patient complete form regardless of where the patient is Prime & additional trng.  Re-emphasize importance of capturing OHI information for the facility and for the patient. And ensure all staff is asking all patients for OHI.  Staff not properly educated on process to collect DD2569s. Two unique days of 100% QC checks; results to be presented at next Deputy Brief Jul 08.Forms were stale-dated. Reinforce need for updated and current-dated forms.Front desk not asking OHI; using just AHLTA. Change to CHCS 1 check in;configure Kiosks. OHI discovery contract submittedFront desk personnel are not checking CHCS to ensure insurance information is current. Audit resullts to clinic leadership.Require clinic staff accept responsibility to complete forms. TPC staff provides clinics with forms & pick up completed forms daily.3 out of 30 records selected in a random audit did not have a current DD 2569 filed in them. Clinics notified to send forms to TPC in timely manner.

NH J AC K S O NVIL L E 8.e - C oding IB WA was not included in the coding contract by F IS C as requested by this command. In order to as sume this additional workload, the command created two additional G S coders . As of this month one pos ition remains unfilled. C ompliance is at its highest for

this fis cal year. The remaining unc oded IB WA are a res ult of allowing the s ys tem to c los e out undoc umented rounds due to our c oding s taff s hortag e and providers utilization of AHL TA c linic al notes to doc ument IB WA rounds . Audits have noted that the AHL TA doc umentation is not being plac ed in the inpatients rec ord. The c ommand is working on proc es s improvements for ens uring AHL TA doc uments for IB WA are inc luded in the rec ord. A P O A&M is included to correct this s ituation.

May 08 comment

This month’s input from same facility8.e C oding IB WA was not included in the coding contract by F IS C as reques ted by this command. In order to as s ume this additional workload, the command created two additional G S coders . As of this month one pos ition s till remains unfilled.. C ompliance continues to be in the high eighties for the las t three months . T he remaining un-coded IB WAs are a res ult of allowing the s ys tem to clos e out undocumented rounds due to our coding s taff s hortage and providers utilization of AHL T A clinical notes to document IB WA rounds . Audits have noted that the AHL T A documentation is not being placed in the inpatients record. T he C oding D ivis ion has implemented a new query/feed back form that is provided to doctors for additional information and to identify any deficiencies noted to increas e the completion and accuracy of the coding. IB WA training has continued to be conducted and all s taff members are s cheduled for C oding B oot C amp.

I like how this MTF repeated the background. It keeps me from having to go back through every month to figure out what is going on. BUT, inpatient documentation should NOT be in the outpatient documentation system we call AHLTA.

Objectives

• Use your DQ metrics appropriately

• Understand “Random” When Applied to Audits

Running a Business

• Would you like to know– Your customers needs– Your customers wants – How much it costs to make your product– For how much you can sell your product

Running a Business

• Would you like to know– Your customers

• ICD-9-CM diagnosis data (6c)• Demographic data (e.g., age, gender, OHI)• Patient categories (PATCATs)

– How much it costs to make your product• Medical Expense Performance and Reporting System

(MEPRS) • Provider specialty codes/HIPAA taxonomy (resident or

physician)

– For how much you can sell your product• Relative Value Units (RVUs) and Relative Weighted Products

(RWPs) (6b, 5)

Data Quality = $$$

• Patient Registration– PATCATS - $$$ -

• $180 M last year (get your Coast Guard, VA, DoD civilians, cosmetic surgery, and civilian emergencies correct…)

– Identifying injuries (Medical Affirmative Claims) - $$$ • $16.5M last year – demonstrates how poorly we identify

these cases

– Other Health Insurance (DD 2569) - $$$• $103.1 M last year

• Documentation - $$$– Must have document filed in record– Coding - $$$

Close

• Close counts in atomic bombs

• Close counts in horseshoes

• Close does not count in coding– If there is no code, then there is no code and

we use an “unlisted code”

• Yes, we do bill for Active Duty services (in MSA we bill Coast Guard, in MAC will bill)

Bottom Line

• It appears that for most bases, there is no problem getting outpatient documentation.

• Is this what you are hearing from your doctors?– For AHLTA documentation, I sure hope it is

there– How are you doing for things not in AHLTA

such as Emergency Department, Obstetrics, Physical Therapy, etc?

What do these slides tell us?

• If TMA has coding resources, they should only be offered to the bases reporting coding below 80%?

• How is your Service interpreting these data?

• How is your Service dividing funds? Manpower? Training slots?

Audits

• All data included population – Each encounter equally likely to be selected– Right now there are encounters in the D and F

MEPRS not being audited, telephone calls…

• Random selection of sample from entire population

• A person will continue to code in the same manner he has coded unless acted upon by an outside source

Random vs Targeted

• Do random to find problem areas– For instance, 100 records with SADRS in a month

from all SADRS in the MTF

• Then do targeted to better define the problem– For instance, you find a nurse practitioner in

pediatrics with diagnosis errors on both records audited. Will you do a more detailed audit of nurse practitioners, or pediatric providers, or all records with the diagnoses that were wrong?

Objectives

• Use your DQ metrics appropriately

• Understand “Random” When Applied to Audits

Questions