Upload
gilbert-parsons
View
214
Download
0
Embed Size (px)
Citation preview
2010 UBO/UBU Conference
1
Briefing: 2008-9 MTF Coding Audit Results for FY2007 Records
Date: 23 March 2010
Time: 1610–1700
2009 UBO/UBU ConferenceTurning Knowledge Into Action
2
Objectives
Understand difference for data flow for different types of encounters (and who is doing the initial coding)
Know the methodology of the audit Be aware of the errors which were frequently identified
2009 UBO/UBU ConferenceTurning Knowledge Into Action MHS Coding Data Flow – Office Visit
How the usual office visit code flows to the central repository
Book appointment Mark appointment as kept
Conduct encounter Document encounter
Provider codes encounter in AHLTA
Codes flow to and are checked by Coding
Compliance Editor (CCE)
Fixed codes flow to CHCS, become a CAPER and flow
to the MDR and M2
Data for logical evidence based decision making
Codes flow to CHCS
3
2009 UBO/UBU ConferenceTurning Knowledge Into Action
MHS Coding Data Flow – Ambulatory Procedure
How the usual ambulatory procedure visit code flows to the central repository
Book appointment Mark appointment as kept
Do procedure Dictate operative report
Coder codes in ambulatory data module of CHCS
Codes flow to and are checked by Coding
Compliance Editor (CCE)
Fixed codes flow to CHCS, become a CAPER and flow
to the MDR and M2
Data for logical evidence based decision making
4
2009 UBO/UBU ConferenceTurning Knowledge Into Action
MHS Coding Data Flow – Inpatient Institutional
How the usual inpatient hospitalization codes flows to the central repository
Write admission order Enter admission data in CHCS
Discharge patient Dictate discharge summary
Inpatient coder abstracts inpatient
record
Coder enters codes in Coding Compliance Editor (CCE) which checks
coding. Coder selects type of DRG.
Codes flow to CHCS, become a SIDR and flow
to the MDR and M2
Data for logical evidence based decision making
5
2009 UBO/UBU ConferenceTurning Knowledge Into Action
MHS Coding Audit Methods– Collected a random sample from all complete
SIDR/SADR for encounters done 30 Sep 2006-1 Oct 2007
– Trained coding auditors followed MHS specific coding guidelines
– QA audits were done to ensure uniform application of coding guidelines
6
2009 UBO/UBU ConferenceTurning Knowledge Into Action MHS Coding Audit of FY2007 Records
Audit Type of Record
Source of Record Service Number in Sample
Annual SIDR Inpatient Army 700
Annual SADR Outpatient, Non-APV Army 700
Annual SADR APV Army 700
Annual SIDR Inpatient Navy 700
Annual SADR Outpatient, Non-APV Navy 700
Annual SADR APV Navy 700
Annual SIDR Inpatient Air Force 700
Annual SADR Outpatient, Non-APV Air Force 700
Annual SADR APV Air Force 700
MERHCF SIDR Inpatient MHS wide 400
MERHCF SADR Outpatient MHS wide 400
11 random samples of FY 2007 medical records drawn from across the direct care system.
Total audit size = 7,100
7
2009 UBO/UBU ConferenceTurning Knowledge Into Action
Outpatient Response Rates by Bencat
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Perc
ent FY 2006
FY 2007
8
2009 UBO/UBU ConferenceTurning Knowledge Into Action
Percent of Outpatient Records that Passed the Audit (only includes records that were received)
0%
10%
20%
30%
40%
50%
60%
SADRArmy
SADRNavy
SADR AirForce
APVArmy
APVNavy
APV AirForce
MERHCFArmy
MERHCFNavy
MERHCFAir Force
Percent
FY 2006
FY 2007
9
2009 UBO/UBU ConferenceTurning Knowledge Into Action
Percent of Failed Outpatient Records with 1 Error
0%
10%
20%
30%
40%
50%
60%
70%
80%
Perc
ent FY 2006
FY 2007
10
2009 UBO/UBU ConferenceTurning Knowledge Into Action
The Percent of Audited Records that Failed the Audit that had any E&M, Diagnosis, Or Procedure Errors. FY 2007 E&M Errors ICD errors CPT Errors SADR Army 54.46% 39.93% 52.48% SADR Navy 59.42% 35.71% 51.62% SADR Air Force 51.67% 40.15% 46.10% APV Army 0.26% 53.25% 74.03% APV Navy 0.25% 37.88% 80.30% APV Air Force 2.44% 35.56% 83.11% MERHCF Army 50.68% 35.62% 52.05% MERHCF Navy 40.91% 34.09% 59.09% MERHCF Air Force 66.67% 42.86% 42.86%
FY 2006 SADR Army 57.66% 46.40% 41.89% SADR Navy 58.11% 49.55% 41.44% SADR Air Force 53.00% 48.50% 40.00% APV Army 1.28% 59.39% 65.23% APV Navy 0.55% 40.14% 84.98% APV Air Force 0.92% 50.67% 83.78% MERHCF Army 52.94% 49.02% 41.18% MERHCF Navy 54.17% 42.86% 53.06% MERHCF Air Force 43.18% 63.64% 52.27%
11
2009 UBO/UBU ConferenceTurning Knowledge Into Action
The Most Common E&M Errors In Audited Records That Failed The Audit E&M not
required Established
patient +/- 1 Level Missing support documentation
FY 2007 SADR Army 14.19% 9.90% 7.92% SADR Navy 14.29% 13.64% 9.09% SADR Air Force 10.04% 10.78% 7.81% APV* MERHCF Army 19.18% 10.96% 2.74% MERHCF Navy 4.55% 11.36% 4.55% MERHCF Air Force 21.43% 14.29% 4.76% FY 2006 SADR Army 16.67% 10.36% 5.86% SADR Navy 13.51% 8.56% 8.56% SADR Air Force 13.50% 13.00% 9.50% APV * MERHCF Army 15.69% 11.76% 7.84% MERHCF Navy 8.16% 8.16% 10.20% MERHCF Air Force 4.55% 6.82% 13.64% *Less than 1%
12
2009 UBO/UBU ConferenceTurning Knowledge Into Action
The Most Common Diagnosis Errors In Records That Failed The Audit Documentation
does not support coded diagnosis
Primary diagnosis not the
reason for the visit
FY 2007 SADR Army 22.11% 3.30% SADR Navy 18.18% 2.60% SADR Air Force 22.68% 1.12% APV Army 27.79% 14.03% APV Navy 22.22% 5.56% APV Air Force 19.78% 8.22% MERHCF Army 23.29% 2.74% MERHCF Navy 22.73% 0.00% MERHCF Air Force 23.81% 2.38% FY 2006
SADR Army 31.98% 6.31% SADR Navy 31.98% 3.60% SADR Air Force 29.00% 5.00% APV Army 35.79% 14.97% APV Navy 21.60% 9.62% APV Air Force 30.89% 10.22% MERHCF Army 29.41% 7.84% MERHCF Navy 16.33% 6.12% MERHCF Air Force 34.09% 6.82%
13
2009 UBO/UBU ConferenceTurning Knowledge Into Action
The Most Common Procedure Errors In Records That Failed The Audit Missing
Support Documentation
Documentation does not
Support Coded procedure
Sequencing
FY 2007 SADR Army 31.02% 13.53% 6.27% SADR Navy 27.27% 12.99% 3.25% SADR Air Force 18.96% 14.13% 6.32% APV Army 11.95% 25.19% 30.39% APV Navy 7.58% 25.00% 20.71% APV Air Force 5.11% 18.89% 17.11% MERHCF Army 27.40% 5.48% 8.22% MERHCF Navy 36.36% 18.18% 2.27% MERHCF Air Force 19.05% 7.14% 7.14% FY 2006
SADR Army 7.21% 27.93% 3.60% SADR Navy 9.46% 22.97% 2.70% SADR Air Force 11.00% 21.50% 3.50% APV Army 8.88% 28.68% 25.13% APV Navy 5.16% 27.23% 22.30% APV Air Force 11.56% 22.89% 27.78% MERHCF Army 3.92% 35.29% 1.96% MERHCF Navy 10.20% 32.65% 4.08% MERHCF Air Force 15.91% 29.55% 6.82%
14
2009 UBO/UBU ConferenceTurning Knowledge Into Action
Estimated Percent of Audited SADR and APVs that were Under or Over Coded*.
APV SADR
Not over or under coded*** 67.45% 53.51%
Over coded 6.63% 26.80%
Under coded 7.15% 2.27%
Can not determine** 18.77% 17.42%
* Based on the type of error found in the record.** Insufficient documentation was provided*** Includes some records which failed the regular audit, but which were not over or under coded.
15
2009 UBO/UBU ConferenceTurning Knowledge Into Action
Percent of Outpatient Records that Passed the Regular Audit and a 'Billing' Audit
0%
10%
20%
30%
40%
50%
60%
70%
80%
Per
cen
t
Regular Audit
Billing Audit
16
2009 UBO/UBU ConferenceTurning Knowledge Into Action
Inpatient Audit Response Rates
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Army Navy Air Force MERHCFArmy
MERHCFNavy
MERHCFAir Force
Per
cen
t R
ecei
ved
FY 2006
FY 2007
17
2009 UBO/UBU ConferenceTurning Knowledge Into Action
The Percent of Inpatient Records that Passed The Audit (only includes records that were received)
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Army Navy Air Force MERHCFArmy
MERHCFNavy
MERHCF AirForce
FY 2006
FY 2007
18
2009 UBO/UBU ConferenceTurning Knowledge Into Action
MTF Coding Audit Study APVs
Most common errors in records that failed APVs: Sequencing of CPT Documentation does not support coded I-9 CPT used does not support documentation Anesthesia not coded Missing supporting documentation Institutional fee (99199) not coded
These account for approximately 75.2% of APV errors.
19
2009 UBO/UBU ConferenceTurning Knowledge Into Action
MTF Coding Audit Study Outpatient
Most common errors in records that failed Outpatient: Documentation does not support coded I-9 CPT codes used do not support documentation (wrong
code) Missing supporting documentation for CPT (nothing to
back up code) E/M code not required but coded Missing supporting documentation for I-9
These account for approximately 56% of Outpatient errors.
Another 13% had no diagnosis coded, procedure or service not coded, wrong category of E/M, CPT sequencing or primary diagnosis not the reason for the visit.
20
2009 UBO/UBU ConferenceTurning Knowledge Into Action
MTF Coding Audit Study Inpatient
Most common errors in records that failed Inpatient: Missing supporting documentation for I-9 Diagnosis not coded DRG assignment error Order of Diagnosis not addressed
These account for approximately 50% of Inpatient errors.
Another 30% had missing supporting documentation for CPT codes, complications and co-morbidities not coded, documentation does not support coded diagnosis
21
2009 UBO/UBU ConferenceTurning Knowledge Into Action MTF Coding Audit Study
Some specifics where coding errors were: Review Coding Guidelines for sequencing, both CPT and
I-9 Review coding guidelines for screening exams
specifically that regardless of the findings or if any procedure is performed as a result of a finding, a screening is still a screening.
Correct coding when APV is cancelled prior to start of procedure
Arthroscopic procedures, coding for compartments of knee
Removal of pin coded but is bundled into procedure
22
2009 UBO/UBU ConferenceTurning Knowledge Into Action MTF Coding Audit Study
Some specifics where coding errors were: Review Coding Guidelines for sequencing, both CPT and
I-9 Review coding guidelines for screening exams
specifically that regardless of the findings or if any procedure is performed as a result of a finding, a screening is still a screening.
Correct coding when APV is cancelled prior to start of procedure
Arthroscopic procedures, coding for compartments of knee
Removal of pin coded but is bundled into procedure
23
2009 UBO/UBU ConferenceTurning Knowledge Into Action MTF Coding Audit Study
Continued “Likely” appendicitis can only be coded as abdominal pain;
“working diagnosis” probable, etc code to highest degree of certainty.
Documentation states “failed conservative treatment”. . . That would support a degenerative, rather than an acute condition.
Mesh insert documented but not coded Surgical approach is coded incorrectly; open, laparoscopic Orthopedic coders should know what a slap lesion is and
should be coding it. Review coding guidelines on when to use E/M, 99499 or
procedure. Removal of a mole has a 10 day global period, so the procedure should be coded and 99499 should be used, not an E/M code.
24
2009 UBO/UBU ConferenceTurning Knowledge Into Action References
DoD Coding Guidelines: http://www.tricare.mil/ocfo/bea/ubu/coding_guidelines.cfm
25
2009 UBO/UBU ConferenceTurning Knowledge Into Action
Easy Fixes – Send the documentation – if the printout from AHLTA
says “see attached document” send the additional document
– Need more than the procedure name to code the procedure
– Inpatient – be sure to use the TRICARE DRG– Ambulatory Procedure –
Be sure to code the anesthesia Sequence the procedure with the greatest weight first
(guidance in 2007)
26
2009 UBO/UBU ConferenceTurning Knowledge Into Action
Easy Fixes – Document the time in and time out for time-based
codes– Consults need a request and written response to the
requesting provider– Avoid unbundling– EKGs – need both the tracing and report to code
93000– Don’t code resolved conditions– Use an External Cause of Injury Code (E-code) for
the INITIAL visit due to an injury
27
2009 UBO/UBU ConferenceTurning Knowledge Into Action
28
Summary of Audit Findings
Outpatient response rates have increased, especially for mobile populations.
The pass rate for outpatient records has increased to around 40%.
The majority of failed records have only 1 error. A higher percentage of outpatient records (especially
APVs) passed a billing audit. Around 27% of SADRs appear to be over coded. The percent of inpatient records passing the audit
increased to around 90%.