Unit 6 - Seminar

Describe the purpose of Quality Improvement Organizations (QIO’s)

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Find your home state. Access the website for that state’s QIO. Briefly summarize two of their current studies, reports, or initiatives.

Unit 6 Worksheet In the following scenarios, what is the issue from a coding quality standpoint?

1.Joyce, a new coder, coded a chart of a patient with “heart failure.” She assigned code 428.9, heart failure (acute) (sudden). The claim was denied by Medicare due to submission of a vague principal diagnosis code. Her supervisor sat down with Joyce, and pointed out that the attending physician documented that the patient had both systolic and diastolic heart failure in two of the progress notes. The doctor also notes this in the assessment area of the discharge summary. In addition, he specifies that it was in the acute phase. What code should have been assigned?

2.Another claim was rejected because code was submitted as the primary diagnosis code for a same day surgery patient who had repair of hallux valgus on June 21. Joyce was also the coder on this chart. The supervisor pointed out to her that the operative report clearly stated that the pre- and post-operative diagnosis was hallux valgus, right foot. What code should have been assigned?

3.A 32-year-old patient is admitted in her first trimester with a diagnosis of hyperemesis gravidarum. The coder code this to and the claim was denied. Again, this was Joyce’s chart. Upon review with the supervisor, it is noted in the admission H&P that the patient was dehydrated. She required IV hydration. On the last progress note, the obstetrician stated that she was dehydrated as well. What should have been coded?

4.In the three scenarios above, it is apparent that Joyce’s quality does not meet standard. What is or is Joyce doing wrong? What can the coding manager do to improve Joyce’s coding quality?

What is Joyce doing wrong?

Not reviewing the entire medical record Codes in #1 and #2 (.9) are vague … should look for more detailed information #3 – a patient would not typically be admitted for mild hyperemesis gravidarum (mild morning sickness) … clue to look for more information

What should Joyce’s supervisor do?

Have Joyce review the coding guidelines of the facility and of CMS again Work closely with Joyce to review several medical records to be sure Joyce does know where to look for detailed information Check Joyce’s quality more often and give Joyce constructive feedback