1 Clinical Documentation and Coding: The Way Forward CAPT Rebecca McCormick-Boyle Assistant Deputy Chief, Current Operations, BUMED M3B

The Process: From Clinical Documentation to Decision Making Resourcing Population Health & Clinical Quality INPUTS OUTPUTS Clinical Documentation Coding

Clinical Documentation & Coding: Decision Making Examples  Population Health & Clinical Quality – HEDIS Measures – Illness & Injuries Frequency & Trends – Force Health Protection & Readiness – Research – Risk Management  Resourcing – Business Case Analysis – Service Line Development – Manpower Assessment – Funding Review – Equipment Plans – PPS earnings

Clinical Documentation & Coding: DQMC Assessment

 Financial recapture opportunity: $61M – Relative Weight Products: $26M by standardizing the provider query process and increasing provider and coder communication. – Evaluation and Management coding: $8M in physical exams. – Ambulatory Procedure codes: $27M through placement in the correct Medical Expense and Performance Reporting System  Population health opportunities: – HEDIS/ Population Health: Gestational diabetes vs chronic diabetic – Procedural data: 1000 cc vs. 1 cc of a pharmaceutical product – Procedural data: 900 procedures vs. 1 procedure provided – Procedural data: Abortions - elective vs. spontaneous  Issues: – Training: #1 reason Navy-wide for DQMC coding deficiencies – Staffing: Numbers; coding competency and MATO contract concerns – Process: Adherence to standard coding audit guidelines – Technology: AHLTA’s coding methodology (i.e., specialty care) Clinical Documentation & Coding: Recovery Audit Assessement

“Just as a complete and accurate medical record coding promotes quality in healthcare delivery, complete and accurate medical record coding promotes quality and clarity in healthcare cost accountability.” -Surgeon General’s Policy Letter on Coding, 1 Oct 2010 Clinical Documentation & Coding: SG’s Assessment

 Coding Program Standard Audit Guidelines, 23 Feb 10  SG’s coding policy letter, 1 Oct 10  HIM coding guidance letter, 8 Nov 10  Navy Medicine coding survey, 24 Nov 10  Project Management Office, 10 Dec 10  MATO Policy Letter, 10 Dec 10  Audit Registry Prototype Letter, 23 Dec 10  Regional Assessment Letter, 14 Dec 10 Clinical Documentation & Coding: Action Plan & Guidance

 Standardize Audit Process  Regional Assessment Visits  Query Process: – Provider – coder communications  Personnel processes – Position Descriptions, Performance incentive, Contracting  Training – Standardized and centralized  E&M Code Guidance – Physical exams in particular (well vs. established) Clinical Documentation & Coding: Program Management Office Action Steps

 Review DQMC and coding processes  Involve clinical and admin leadership in DQMC review  Include PAD officer in the DQMC process  Engage PAD officer in reporting and action planning  Review audit findings (trend analysis)  Increase your audits: – Sample size > 30 minimum – Focused reviews/root cause analysis of DQMC statement error and reason codes Clinical Documentation & Coding: Recommended MTF Action Steps

 Decision Making Based on Accurate Data  Strong Foundation for ICD-10 Implementation  Acknowledge the importance of our clinical staff’s valuable time and effort and our responsibility to invest in the resources needed to capture clinical documentation  Enhanced understanding of the health of those we serve Clinical Documentation & Coding: The Goal