LVF Audits – an Overview This training is provided by the Missouri Cancer Registry MCR gratefully acknowledges Angela Martin, CTR who developed the Power Point presentation used as the basis for this training. Disclaimer- Missouri Cancer Registry presents this training as a learning tool for hospital staff who report cancer cases to the central registry. This tool should not be used to determine medical diagnoses. Persons seeking CMEs or CEUs should check with their accrediting organization to determine if this training meets their criteria for educational credits. This project was supported in part by a cooperative agreement between the Centers for Disease Control and Prevention (CDC) and the Missouri Department of Health and Senior Services (DHSS) (5NU58DP003924-05) and a Surveillance Contract between DHSS and the University of Missouri.

Objectives To understand the purpose of an Audit To understand the steps in the Audit process

Audits Required by National Program of Cancer Registries Each Missouri hospital is audited within a 5 year time period to assist with casefinding and abstracting Audits are for educational purposes, not punitive

Audits MCR conducts a standard casefinding audit on LVFs – basically we receive your MRDI and compare that to our database When NPCR conducts an Audit on MCR – a few hospitals will be requested to provide data…the audit is not on your facility but on MCR

How will I know I am up for an Audit? A letter is sent to the Facility Contact and Administrator so that he/she will be aware that you are undergoing an audit. We will also contact you via email and phone once letters have gone out. We may request additional information if we do not have it

What will I need? Medical Record Disease Index. With the MRDI we would normally use the one that was previously submitted with your data submission. If the MRDI is not in the proper format or missing vital information for us to conduct our Audit we will request that another MRDI be submitted. Admission Key/Service Code Report. If your admission key/service code is a number we do need a report telling us what the number corresponds to. Submission of above within 2 weeks of audit notification

Medical Record Disease Index Your MRDI should include these fields: First and Last Name Date of Birth Social Security Number Service Code Admission and Discharge Date Medical Record Number ICD-10 codes Procedure codes (if any) ICD-10-PCS codes (if any)

EXAMPLE OF MEDICAL RECORD DISEASE INDEX NAME DOB SSN SERV CODE ADM DATE DIS DATE MR# ICD-10 CODES     DESCRIPTION PROC CODES DESCRIPTION AAAA 12/01/50 333224444 OPS 06/15/16 12345 C50.9 Malignant neoplasm of breast 0HBT0ZZ Local excision SURG 07/01/16 07/04/16 0HTT0ZZ Right simple mastectomy C78.7 Secondary liver mets 0W9930Z Right catheter insertion for drainage I10 Hypertension BBBB 12/31/69 444556666 12/01/16 10101 K92.1 Blood in stool 0DBP0ZX Open biopsy of rectum C20 Malignant neoplasm of rectum XRT 12/10/16 Z51.0 Radiotherapy DD073ZZ Teleradiotherapy using electrons CCCC 01/13/30 111223333 03/02/16 7777 D33.2 Benign neoplasm of brain B030ZZZ MRI of brain

Medical Record Disease Index Generating or compiling a useful MRDI may require the help of your IT department. Your software system may produce a text file which you can then be imported into an Excel spreadsheet. The Excel spreadsheet can submitted to us. There are very specific things we request. The MRDI needs to be in alphabetical order by last name The MRDI should include the social security number It is also important to annotate the MRDI

Audit Process Review Resolution Reconciliation and Finalization

Audit Process Review The Review portion takes place at MCR We review your MRDI against our database, and anything that is not present in our database we will place on a pull list for your facility and will fax to you We will send an email/call to set up the resolution call

Audit Process Resolution Charts from the pull list for the dates of service specified should be available and ready to discuss during the call Each case will be discussed to determine whether the case should be reported. We may ask about several cases that you correctly found to be non-reportable, which will only confirm your skills During the call, we may create a list of missed cases that would need to be submitted in the same manner as your regular quarterly submissions. Please note that these are missed cases from the audit by placing those comments on the transmittal form.

Audit Process Reconciliation and Finalization Audit Report sent to facility contact contains kudos, suggestions and completeness rate Letter to administrator notifies them that the Audit is complete

Positives of Audit Administrator becomes aware of the great job you are doing Helpful tips to improve casefinding Overall goal is to improve our collaborative cancer reporting efforts