1. 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) (5NU58DP ) and a Surveillance Contract between DHSS and the University of Missouri.

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

3. 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

4. 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

5. 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 and phone once letters have gone out.
We may request additional information if we do not have it

6. 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

7. 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)

8. 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
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
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
03/02/16
7777
D33.2
Benign neoplasm of brain
B030ZZZ
MRI of brain

9. 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

10. Audit Process
Review
Resolution
Reconciliation and Finalization

11. 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 /call to set up the resolution call

12. 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.

13. 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

14. 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