Internal Coding Auditing Programs Gloria Litton, RHIA, CCS AHIMA Approved ICD-10-CM/PCS Trainer

The Need For Coding Audit Programs The OIG Compliance Program Guidance for Hospitals states that "an ongoing evaluation process is critical to a successful [coding] compliance program The data provided by coders is invaluable to an organization in order to provide appropriate data collection and safeguard against the increasing level of external scrutiny of the coded data.

The Benefits Of Auditing To keep performance and compliance on track Provide ongoing feedback on coding staff performance Improve quality of existing coding staff Identify missed opportunities Decrease delays in dropping records Decrease DNFB

Factors Leading To An Enhanced Coding Audit Program New coding associates ◦ Associate turnover/retirement ◦ Additional or expanded hospital services ◦ Focus on Revenue Cycle and development of more stringent DNFB goals Increased external re-review activities ◦ DRG validation requests from payers ◦ RAC/Other regulatory reviews Increased organizational quality review programs ◦ Core Measures Increased payer denials and rejections Preparing for ICD-10 implementation

Mary Washington Healthcare’s Internal Auditing Plan Where we started ◦ One Auditor/Educator  Chart reviews  DRG Validation Reviews from internal and external requestors ◦ Quarterly External Audits  Each patient type was reviewed once a year ◦ Limited Outpatient Reviews  Focus was on inpatient reviews  Limited time to complete reviews on all patient types

How We Progressed Focus on coding quality AND productivity Hired additional coding compliance auditors Increased coding reviews for each coder Developed a coding review schedule to include all coders and all patient service types ◦ Increased focus on outpatient coding Maintained our quarterly external review schedule ◦ Each patient type is reviewed on a quarterly basis by an outside coding auditing organization

Coding Associates ◦ 18 coding associates  10 inpatient coders  4 outpatient coders  Charge entry for IR and Cardiac Cath  4 emergency room coders  Charge entry for ER services and level of care ◦ 4 coding auditors  2 Inpatient Auditors  Inpatient reviews/RAC reviews/ DRG Validation Reviews  Inpatient reviews/Internal Quality Reviews  2 Outpatient Auditors  Outpatient reviews/Denials and rejections  Emergency Room reviews/Auditing software and system testing

Coder Reviews Increased the number of individual coder reviews ◦ Quarterly reviews for each coder ◦ Minimum of 30 records per review  Random selection  Patient Service Type ◦ Re-reviews for audit scores less than the coding accuracy standard of 95%  Additional review of 30 records within one month of the initial review Incorporated accuracy scores into annual performance evaluations ◦ Coding accuracy scores are 35% of total job competencies on annual performance evaluations ◦ Coding standards set to match the performance evaluation categories (meeting expectations, exceeding expectations, and needs improvement)

Auditing Tools Implementation of electronic auditing software ◦ Automatically uploads ADT information and codes from abstracting software ◦ Auditor randomly selects 30 charts from the that monthly ◦ Codes from audit results are entered into the auditing software Development of audit result tools ◦ Audit Review Schedule developed ◦ Audit Review Packets are created for each review  Audit Summary Spreadsheet  Reports from individual records are generated

Second Level Review Process Increased internal quality reviews ◦ Core Measures ◦ Readmissions Developed an automated review process ◦ Developed an internal coding review  Records referred from clinical quality review programs are ed to the account  Monitored by coding compliance auditor  Reviews and responds to requestors ◦ Automated a pre-bill review workflow process  Coders cannot finalize records that meet certain criteria  Records can only be finalized by the coding compliance auditors

Results Met the 95% coding accuracy standard for 2012 and year-to-date for 2013 Every coder was reviewed internally for each quarter in 2012 and once externally by coding auditing vendor Increased coder satisfaction and confidence through ongoing feedback and education

Future Plans Increase number of coding compliance auditors to allow for increased coding reviews and new coding associates added prior to and following ICD-10 implementation in 2014 Coding Compliance Auditors will begin dual coding of audited records and share results with coding associates during regular quarterly reviews Coding Compliance Auditors to assist with education of ICD-10-CM/PCS for coding associates, CDI nurses, Revenue Integrity, Ancillary Departments, and all other associates identified by the ICD-10 Steering Committee as needing ICD-10 education

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