To code, or not to code: that is the question: Whether 'tis nobler in the mind to suffer (786.5) The calls and emails of outrageous fortune, Or to take arms against a sea of uncoded T’cons, And by opposing end them? To be denied leave, and sleep (307.41) No more; and by taking leave we temporarily end The heart-ache (419.9) and the thousand emails That my in-box is heir to, 'tis a consumption (011.9) Devoutly to be wish'd against. Jim Cox, in his year of discontent 2005
Transcript
To code, or not to code: that is the question: Whether 'tis nobler in the mind to suffer (786.5) The calls and emails of outrageous fortune,Or to take arms against a sea of uncoded T’cons,And by opposing end them? To be denied leave, and sleep (307.41)No more; and by taking leave we temporarily endThe heart-ache (419.9) and the thousand emailsThat my in-box is heir to, 'tis a consumption (011.9)Devoutly to be wish'd against.
Jim Cox, in his year of discontent 2005
Coding Overview and the Commander’s Statement
May 2008
DQMC
Why this matters to Data Quality
• Coded data is used to make decisions regarding:– Population health– Funding– Anticipating which mix of providers is needed– Justifying new equipment
• You need to know the quality of your data to decide how much to trust it
How this affects DQ
• This talk is mostly about – How to ensure your reported data are correct– How to do an audit that actually tells you
something
Ways to employ this info in your DQ programs
• We will discuss the most successful ways to improve your coding– Teach– Use– Audit – this includes taking action on issues
found during the audit and correcting them, permanently
Goal
• Quality data on which to base sound decisions– For you– For your Commander– For your Service– For the Military Health System (MHS)
Data Goal Corollary
• You give me bad data, I’ll make bad decisions
Suggested Coding “Solution”
• Have each new provider, prior to receiving privileges to practice at your MTF, spend 4 hours with a good coding trainer– Option to “test out” of the class by passing
test composed of examples of quality documentation which the provider will enter the correct diagnoses/external causes of injury, evaluation and management code(s) with modifiers, procedure code(s) and any other applicable HCPCS code(s)
Coding Basics
• International Classification of Diseases– Diagnoses, why patients seek/receive care– Also used for inpatient institutional workload– Explains why the provider did the service
• Used to support medical necessity
• Current Procedural Terminology– Type of service furnished, office visit, x-ray– Used for professional services workload– Used for outpatient institutional workload
Coding Basics
• Codes are assigned based on documentation • Diagnosis codes are assigned differently based
on the setting (inpatient or outpatient)• Military Health System has special coding
requirements, which are logical, and are needed to accurately reflect services
2. a. O utpatient C oding C ompletion in 3 days . P roviders have been identified and training provided on the importanc e and effec ts of not s ig ning the pt rec ord within the 3 day requirement not to wait for tes t res ults and that if they g o in after the rec ord has been s ig ned and c ompleted to make any c hang es it opens the rec ord and makes it delinquent until they s ig n off on it ag ain. T raining has been provided to the c linic s to run the ADM R eport “Appointments with no ADM R ec ords “, daily to ens ure that the providers are c los ing out in a timely manner.
2a. E mergency room is 491 encounters behind in their coding efforts . S till experiencing is sues with AHL T A to ADM write back. P lan: D irectorate's , Department Heads and Medical Adminis trative O fficers have continuous ly pushed for uncoded encounters to be coded and s igned. Additionally we are noticing ins tances where an encounter has been completely coded and s igned via AHL T A, however does not write back to ADM. T hese errors have been called into our local MT F help desk and escalated to MHS T ier 3 for additional support. T he following MHS tickets numbers have been logged: 12273103, 12635555, 13542508 and 13605125. Will continue to monitor errors and uncoded encounters and provide timely reporting so that compliance and resolution can take place in an expedient time frame.
2b: P roviders are not completing records in a timely manner. Weekly reminder goes out to the providers to inform them of the s tatus of inpatient record delinquencies . Weekly reminder has been forwarded via the chain of command for vis ibility and action. Department Head has implemented tracking of delinquent Inpatient Medical R ecords in compliance with J oint C ommiss ion s tandards as mandated by B UME D. E T C : O ngoing as there are newly reported providers on deck.
2a. T imeliness is s till currently an is sue. HC O s ends weekly delinquent ADM emails to department
heads . Also E D uses "dummy" codes to ensure the timely capture of workload. Our coders also provide on-going provider training at C ommand Indoctrination and via the AHL T A working group.2b. 48 of 104 patient records had no ADM entry for coding. C oders have incorporated "dummy" codes in the AP U to ensure the timely capture of workload.2a- C ompletion of outpatient encounters within the three day requirement has been a s ignificant challenge for our MT F this year. A P OA&M for improvement has been submitted to address this deficiency. Additionally, AHL T A generated errors continue to pers is t which contributes to the provider’s inability to code the encounter in a timely manner. T he following trouble tickets related to DQ have been submitted and remain ***** UNR E S O L VE D ******:
6. b.c.d. O utpatient E &M, IC D9 and C P T C oding Validation- A P O AM has been established. F our providers are working as C hampions to ass is t in assuring that other providers attend the C oding T emplate T raining, templates are loaded on computers and there to ass is t as the P O C between the trainer and the clinics . T here are three training phases – 1 - Initial training, 2 - Monitor R VU/Increased AHL T A usage and refresher training 3 – L eadership support. E ach training sess ion will be 1.5 hours per course on F riday afternoon with 10-15 s tudents per class . G radually this process will ass is t with coding accuracy and provider proficiency with AHL T A.
NHL is working closely with NMW and B UME D on improving coding accuracy for NHL and the R emote C oders . We submitted another 25 examples of Nov records that we think were coded incorrectly by contract coders to B UME D for review. Dec 11 there was another teleconference to discuss the findings with S usan P ierce, L T E dusada, L C DR Haradon, E NS T elman and the DQ Manager. We are working out is sues identified. T raining will be provided to the contract coders on their errors , NHL coders were not aware of all that was needed on immunization documentation and the coding contract has decreased the number of remote coders that were previous ly coding NHL records . NHL is currently in the process of recruiting a certified coder to work in the facility.
6c. Outpt ICD-9
Reporting Month Dec 07 Jan 08 Feb 08 Mar 08 Apr 08 Data Month Oct 07 Nov 07 Dec 07 Jan 08 Feb 08
7b, c: All AP Vs are s ent to contractor for coding and auditing. E ducation of the external coders is on-going by the Auditor/T rainer. A tremendous amount of communication has occurred this pas t month regarding the uniquenes s of military coding and anticipated compliance of s ame should be expected within 30 days .
7c. APV CPT
Reporting Month Dec 07 Jan 08 Feb 08 Mar 08 Apr 08 Data Month Oct 07 Nov 07 Dec 07 Jan 08 Feb 08
8e. Interns continue to document without indicating s taff involvement. Vis its have to be canceled if s taff s ignature is miss ing. L ack of inpatient services documentation by providers has resulted in R NDS appointments being canceled. Military Health S ys tem C oding G uidance, P rofess ional S ervices and S pecialty C oding G uidelines , Vers ion 2.0, 1 S ep 07 S ection 9.3.3.1. s tates : If house s taff sees the patient and the attending provider is not phys ically present during the portion of the service that determines the level of service and the attending does not document the key components of those services , no R NDS encounter will be completed. T he R NDS appointment for that date should be cancelled… ”.NH J AC K S O NVIL L E 8.e - C oding IB WA was not included in the coding contract by F IS C as requested by this command. In order to as sume this additional workload, the command created two additional G S coders . As of this month one pos ition remains unfilled. C ompliance is at its highest for
this fis cal year. The remaining unc oded IB WA are a res ult of allowing the s ys tem to c los e out undoc umented rounds due to our c oding s taff s hortag e and providers utilization of AHL TA c linic al notes to doc ument IB WA rounds . Audits have noted that the AHL TA doc umentation is not being plac ed in the inpatients rec ord. The c ommand is working on proc es s improvements for ens uring AHL TA doc uments for IB WA are inc luded in the rec ord. A P O A&M is included to correct this s ituation.
9. (E.4.c) # of AHLTA SADR encounters / # of Total SADR encounters.
9. F or management us e and tracking purpos es only. T he is s ue remains unres olved, but improvements are expected based on increas ing pers onalized training and adjustments to AHL T A clinical templates . AHL T A will be deploying an inproces s ing module in the future, but the date for deployment is not available, so the is sue is being cons idered by the sys tem developers . T he new data champion at the B ranch C linics will be managing improvements to the workflow iss ues that will contributing to reducing our AHL T A utilization compliance numbers , and MID will continue to as s is t. Network connection is s ues are s till being monitored, and a network utilization s tudy has been requested, although it does not appear this is the main is s ue caus ing the lack of utilization.
Objectives
• Use your DQ metrics appropriately
• Understand “Random” When Applied to Audits
Running a Business
• Would you like to know– Your customers needs– Your customers wants – How much it costs to make your product– For how much you can sell your product
Running a Business
• Would you like to know– Your customers
• ICD-9-CM diagnosis data (6c)• Demographic data (e.g., age, gender, OHI)• Patient categories (PATCATs)
– How much it costs to make your product• Medical Expense Performance and Reporting System
(MEPRS) • Provider specialty codes/HIPAA taxonomy (resident or
physician)
– For how much you can sell your product• Relative Value Units (RVUs) and Relative Weighted Products
(RWPs) (6b, 5)
Data Quality = $$$
• Patient Registration– PATCATS - $$$ -
• $180 M last year (get your Coast Guard, VA, DoD civilians, cosmetic surgery, and civilian emergencies correct…)
– Identifying injuries (Medical Affirmative Claims) - $$$ • $16.5M last year – demonstrates how poorly we identify
these cases
– Other Health Insurance (DD 2569) - $$$• $103.1 M last year
• Documentation - $$$– Must have document filed in record– Coding - $$$
Close
• Close counts in atomic bombs
• Close counts in horseshoes
• Close does not count in coding– If there is no code, then there is no code and
we use an “unlisted code”
• Yes, we do bill for Active Duty services (in MSA we bill Coast Guard, in MAC will bill)
Bottom Line
• It appears that for most bases, there is no problem getting outpatient documentation.
• Is this what you are hearing from your doctors?– For AHLTA documentation, I sure hope it is
there– How are you doing for things not in AHLTA
such as Emergency Department, Obstetrics, etc?
What do these slides tell us?
• If TMA has coding resources, they should only be offered to the bases reporting coding below 80%?
• How is your Service interpreting these data?
• How is your Service dividing funds? Manpower? Training slots?
Audits
• All data included population – Each encounter equally likely to be selected– Right now there are encounters in the D and F
MEPRS not being audited, telephone calls…
• Random selection of sample from entire population
• A person will continue to code in the same manner he has coded unless acted upon by an outside source
Random vs Targeted
• Do random to find problem areas– For instance, 100 records with SADRS in a month
from all SADRS in the MTF
• Then do targeted to better define the problem– For instance, you find a nurse practitioner in
pediatrics with diagnosis errors on both records audited. Will you do a more detailed audit of nurse practitioners, or pediatric providers, or all records with the diagnoses that were wrong?
Your Commander Signs:
9. I am aware of data quality issues identified by the DQMC Review List and when needed, have taken action to improve the data from my facility.
