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CONDUCTING A CODING
PROCESS INVENTORY TO ASSIST IN DEFINING YOUR AUDIT
IN DEFINING YOUR AUDIT ACTIVITIES
PRESENTED BY PRESENTED BY: SHERYL VACCA
SENIOR VICE PRESIDENT/CHIEF COMPLIANCE AND AUDIT OFFICER
UNIVERSITY OF CALIFORNIA RYAN MEADE
MEADE & ROACH, LLP
AHIA 31st Annual Conference – August 26-29, 2012 – Philadelphia PA
Goals
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1. Describe the integration of the results of a coding process 1. Describe the integration of the results of a coding process
inventory into the auditing plan
2. Propose an “ideal” coding process flow for who and when
codes are chosen
3. Develop a coding process inventory approach that defines
risk points based on deviation from “ideal”
Note: Deviation from ideal does not mean error but it points to risk Note: Deviation from ideal does not mean error, but it points to risk
4. Discuss common deviations from the “ideal” and audit plan
responses
Integrating the results of a coding process
inventory into the auditing plan
inventory into the auditing plan
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Traditional coding audit choices:
High volume High volume High dollars Past problems New service lines
Government-identified national risk areas Unique risks to organization
But…
Health care providers are growing more complex with a greater number of
access points for charge capture
C d b i h l ( h i )
Codes are being chosen closer to (or the same time as) an event
Integrating the results of a coding
i
t
i t th diti l
process inventory into the auditing plan
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An audit of a claim against the medical record can
An audit of a claim against the medical record can
find an error rate, but in today’s complex patchwork
of electronic systems, does it tell you anything about
real risk if the auditors do not understand the system
and process flow?
Along with traditional methods for choosing audit
Integrating the results of a coding
i
t
i t th diti l
process inventory into the auditing plan
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A coding process inventory assesses where there
A coding process inventory assesses where there
are risk points in the flow of information which leads
to the choice of a code
Claims audits can then be targeted for items and
Claims audits can then be targeted for items and
services which are coded through a coding process
which deviates from the “ideal”
Integrating the results of a coding
i
t
i t th diti l
process inventory into the auditing plan
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A coding process inventory uses an “ideal” coding
g p
y
g
process flow and identifies how clinical areas
deviate from the ideal
Basic steps:
Identify an ideal flow
(we propose one!)
Trace process for how codes are chosen and end up on
a claim
a claim
Identify the point a code is chosen and who chooses the
Defining an “Ideal”
C di P
Fl
Coding Process Flow
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Important Notes:
po a No es:
An “ideal” coding process flow does not guarantee error-free results, rather it sets out a process which best manages coding , p g g selection risk
N h h “ d l” d fl d
Not having the “ideal” coding process flow does not mean a site has errors, but it suggests where not-for cause auditing should occur
“Ideal” Coding Process Flow
g
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We propose the following as the “ideal” coding
We propose the following as the ideal coding
process flow:
ifi d d i
d
i
f
a certified coder reviews documentation of a
clinical event and chooses codes from the
d
t ti b f
h
t t
documentation before a charge posts to a
claim.
Is the “ideal” realistic?
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It used to be the “norm”!
Our proposed “ideal” provides the safest approach for coding
compliance, but…
With the introduction of EMR, there is a trend to push the
coding decisions as close to the clinical event as possible coding decisions as close to the clinical event as possible
The culture of EMR is to “let the system do it”
The ideal is considered a luxury by many organizations The ideal is considered a luxury by many organizations
Steps in an “Ideal”
C di P
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Coding Process Flow
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1. Physician writes an order for a service. 2. Service is scheduled.
3. The service occurs and is documented in the medical record (including
any required reports if the service is a diagnostic test).
4. The medical record is reviewed by a certified coded who chooses
codes.
5. Only after coding occurs is the charge posted to the patient’s account
“Ideal” Coding Process Flow Process Flow
Top Items Which Introduce Risk into
C di P
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Coding Process Flow
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1. Reliance on physician to choose code.p y
2. The charge posts to patient’s account at time of
d / h d l
order/scheduling.
3 Hospital coding and Physician coding offices do not 3. Hospital coding and Physician coding offices do not
coordinate.
4. Code checking occurs electronically and certified coders
“Ideal” Flows in Hospital Setting
p
g
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The following two flows provide examples of the
The following two flows provide examples of the
“ideal” in the context of:
1.
When the hospital and professional coding functions
are unified
2.
When the hospital and professional coding functions
“Ideal” When Hospital &
Physician Coding Function is Unified
“Ideal” When Hospital & Physician Coding Offices are Separate
“Ideal” Flows in Three Other clinical
areas
16Pharmacy
Lab
Imaging
“Ideal” Coding Flow for
h
Pharmacy
I t t f t f Important features for managing coding risk:
9 Drug not charged until administered
9 Coding occurs after administration
“Ideal” Coding Coding
Flow for Lab
Important features for Important features for managing coding risk:
9 Physician does not provide ICD-9 code b i but writes out diagnosis or reason for test
9 Charges do not post g p upon order or
specimen gathering
9 Blood draw stations do not use previous do not use previous visit information
9 Coding based on test performed
“Ideal” Coding Flow for Imaging
Important features for managing coding risk:
9 Coding and charges do not occur until after radiologist reads report reads report 9 Natural language software is audited 100% checked until th fi i there are proficiency tests developed and met
9 Well suited for coding hospital and professional services at same time
Conducting the coding process
i
t
inventory
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Review a clinical area
Document when a code is chosen
Is the code chosen before a charge posts? Is the code chosen at time of service?
Is a code choice necessary for a physician to “close out” an encounter?
Document who chooses the code
Is the code chosen by a certified coder?
What training does the individual have if not a coder? What training does the individual have if not a coder? Is the code chosen by a physician?
Who codes the hospital charges versus the professional charges? What tools are used to assist in choosing the code?
7 Observations on
C di P
Fl
Ri k
Coding Process Flow Risks
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1. An EMR should not be assumed to directly assist in managing
coding risks coding risks.
2. There is a trend nationally to rely heavily upon physicians to y y y p p y
choose codes in the EMR or on paper encounter forms. Th d i i b id t f tifi d
3. The decision by providers to move away from certified
coders choosing codes is not dependent upon EMR implementation.
The decision is usually an operational and budgetary choice.
There are significant consequences to this choice, including the need for
7 Observations on Coding Process Flow
Ri k
Risks
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Th i wi t d t t l l i
4. There is a growing trend to use natural language processing
software to “read” text and assign codes, particularly in radiology. We expect this trend to continue throughout the country. Organizations should know where natural language software is used.
5. Hospital billing and Physician billing offices may be siloed
with little to no communication between them.
This may be due to the legal structure of having separate entities Even in common governance organizations they could be separate
7 Observations on Coding Process Flow
Ri k
Risks
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6 Efficiency goals tend to push coding decisions and 6. Efficiency goals tend to push coding decisions and
charge capture as close to ordering and scheduling as possible
This creates compliance risk if the test performed is not the same as test scheduled or ordered or if the test never occurs
7. EMR templates present the same coding risks as pre-designed paper encounter forms.
Some suggestions for audit response to common
coding process inventory results
coding process inventory results
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Response will be unique to organization, but common needs at h l h
health care organizations:
1. Identify what clinical areas use natural language software and whether
the clinical area self-audits the natural language software. Any area which does not audit 100% of natural language coding software should be audited until software’s proficiency level is reached.
be audited until software s proficiency level is reached.
A h it l’ t t f f ilit E&M d h ld b i d t
2. A hospital’s strategy for facility E&M codes should be examined to ensure
there is a hospital-wide consistent approach among clinical departments. .
Suggestions for Coding Audits
(G
l)
(General)
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3. Outside coders that do not have routine auditing or monitoring by
appropriate campus staff should be audited. A sample of claims which were coded by the outside coders should be audited and proficiency expectations set.
4 Service areas that charge at point of order should be audited 4. Service areas that charge at point of order should be audited.
Identify the clinical areas that capture charges based on orders.
Capturing charges at the time of an EMR order poses risk that the test performed is
Suggestions for Coding Audits
(G
l)
(General)
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5. Service areas that have auto-populate and/or copy and p p / py
paste functionality turned on in the EMR should be audited
6. If the organization is in an EMR transition, liaison with EMR
transition team to identify process flows that move coding transition team to identify process flows that move coding decisions close to the clinical event
Suggestions for Coding Audits
(G
l)
(General)
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7. The first year of EMR conversion should have samples pulled equally
from each quarter during the year to plot risk which may have occurred as functionalities in the EMR are adjusted.
During the first year of EMR implementation there are often numerous adjustments and
re-work done
8. Are physicians coding from smartphones?
There is increasing integration of smart phones and tablets with the
EMR h i h h i i ? EMR – what is the process physicians use?
Take-away Points
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Auditing plans need to respond to changing times
Traditional coding audits assume the main process flow is a coder (or
knowledgeable person) chooses a code based on documentation knowledgeable person) chooses a code based on documentation
Auditing plans need to stay abreast of changing coding processes and
h fl h h d l incorporate the process flow changes into their audit plan
A coding process inventory identifies when a code is chosen and whog p y
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QUESTIONS?
Presenters Contact Information:
Sheryl Vacca 0 98 9090 510-987-9090 [email protected] Ryan Meade 312.498.7004 [email protected]
