The health information management team at Anywhere University Hospital (AUH)

The health information management team at Anywhere University Hospital (AUH) contracted with an auditing firm to perform full assessment coding review. The results from this baseline assessment are provided in four tables:

• Variation Log by Type of Error
• Variation Log by Coder
• Variation Log by MS-DRG
• MS-DRG Relationship Assessment

You are the inpatient coding manager at AUH. Your director has asked you to develop an ongoing review and monitoring schedule for the next year based on the results from the outside review.

Include internal and external reviews, coding in-services, physician workshops, and external seminars/educational sessions that will be performed and or provided for your staff. The schedule should be specific (include volumes and/or percentages of charts to be reviewed). Keep in mind that on average it takes 18 minutes to review one inpatient chart. Budget provides for $65,000 for external reviews. The average cost for reviewing one inpatient record by an external review team is $55.00 (fully loaded).

In addition to preparing the schedule, outline how you will maintain coding quality statistics and report them back to the HIM Director and Compliance Committee at your facility.

• How will you reward your staff members who show great improvements?
• How will you reward and/or recognize that your staff has made improvements overall?

Your Coding Team consists of:

Coding Manager (you)

1-Data Quality Auditor (1 FTE)

8-Inpatient Coders (8 FTE)

2-RHIA, CCS

3-CCS

3-RHIT

Results of the full assessment coding review for AUH:

Two audits were performed:

1. Coding quality review by MS-DRG

2. MS-DRG Relationship Analysis

Variation Log by Type of Error	% of errors
Inaccurate sequencing or specificity principal diagnosis, affect MS-DRG	17%
Inaccurate sequencing or specificity principal diagnosis, non affect MS-DRG	16%
Omission CC, affect MS-DRG	33%
Omission CC, non affect MS-DRG	2%
Inaccurate principal procedure, affect MS-DRG	3%
Omission procedure, affect MS-DRG	4%
More specific coding of diagnosis or procedure, non affect MS-DRG	12%
Inaccurate coding	5%
Missed diagnosis or procedure code	8%

Variation Log by Coder
Coder	Error Rate	Standard
Coder 1	3%	5%
Coder 2	9%	5%
Coder 3	8%	5%
Coder 4	2%	5%
Coder 5	4%	5%
Coder 6	16%	5%
Coder 7	12%	5%
Coder 8	3%	5%

Variation Log by MS-DRG*
MS-DRG	Volume	Error Rate
470	420	2%
313	233	14%
392	232	1%
291	232	17%
247	220	3%
292	216	5%
871	213	12%
641	209	0%
194	195	3%
293	193	1%
885	188	3%
312	177	0%
191	175	7%
287	173	2%
310	171	15%
689	157	11%
603	143	2%
379	137	3%
192	131	9%
683	116	11%
189	114	1%
069	110	2%
190	92	12%
193	87	10%
690	76	4%
065	76	5%
195	72	2%
066	52	2%
064	41	5%
906	35	2%

*MS-DRG descriptions provided below

Variation Log by MS-DRG* Set
MS-DRG Set	Hospital %	Nation %
064	24.3%	21.4%
065	45.0%	43.8%
066	30.8%	34.8%
190	23.1%	15.2%
191	44.0%	33.5%
192	32.9%	51.3%
193	24.6%	17.5%
194	55.1%	54.2%
195	20.3%	28.3%
291	34.6%	29.2%
292	36.7%	38.8%
293	28.8%	31.9%
689	67.4%	21.7%
690	32.6%	78.3%

*MS-DRG descriptions provided below

MS-DRG	MS-DRG Title (FY 2008)
064	Intracranial hemorrhage or cerebral infarction w MCC
065	Intracranial hemorrhage or cerebral infarction w CC
066	Intracranial hemorrhage or cerebral infarction w/o CC/MCC
069	Transient ischemia
189	Pulmonary edema & respiratory failure
190	Chronic obstructive pulmonary disease w MCC
191	Chronic obstructive pulmonary disease w CC
192	Chronic obstructive pulmonary disease w/o CC/MCC
193	Simple pneumonia & pleurisy w MCC
194	Simple pneumonia & pleurisy w CC
195	Simple pneumonia & pleurisy w/o CC/MCC
247	Perc cardiovasc proc w drug-eluting stent w/o MCC
287	Circulatory disorders except AMI, w card cath w/o MCC
291	Heart failure & shock w MCC
292	Heart failure & shock w CC
293	Heart failure & shock w/o CC/MCC
310	Cardiac arrhythmia & conduction disorders w/o CC/MCC
312	Syncope & collapse
313	Chest pain
379	G.I. hemorrhage w/o CC/MCC
392	Esophagitis, gastroent & misc digest disorders w/o MCC
470	Major joint replacement or reattachment of lower extremity w/o MCC
603	Cellulitis w/o MCC
641	Nutritional & misc metabolic disorders w/o MCC
683	Renal failure w CC
689	Kidney & urinary tract infections w/ MCC
690	Kidney & urinary tract infections w/o MCC
871	Septicemia w/o MV 96+ hours w MCC
885	Psychoses
906	Hand procedures for injuries

Submit the following question to think about as you design this:

Who will be responsible for providing education regarding coding issues?

Who will be responsible for arranging clinical education sessions?

Who will audit charts?

Who will answer coding questions for the coders?

Who will monitor coding improvement and provide progressive discipline when required?

Note: The more administrative duties given to the data quality auditor, the fewer number of charts he or she can review on a daily basis.

Please also include the following:

1. A schedule that optimally utilizes the data quality auditor’s position before scheduling external reviews that have an additional cost. The data quality auditor’s review schedule should be designed not to delay the completion of accounts for billing. If the DQA has piles of charts to review, then the bills are not being released for payment. The workflow must be logical.
2. There should be at least one education session per month. The month of September should include an in-service for ICD-9-CM updates, and December should include an in-service for CPT/HCPCS updates. Keep in mind that scheduling too many sessions per month may negatively affect productivity.

Educational topics should be related to clinical areas where there was significant MS-DRG coding variation [Respiratory, Cardiology and Vascular Services].

Educational topics should relate to coding areas identified in the Variation Log by Type of Error including:

1. Correct coding of major complications and comorbidities and complications and comorbidities

i. This is again emphasized in the MS-DRG relationship assessment where several pairs of with and without MCC/CC MS-DRGs are reported at a higher rate at the hospital than in the state.

1. Correct sequencing of diagnoses
2. Specificity of codes

i. A conversation regarding documentation issues may be warranted here.

1. Be CREATIVE!

Reporting coding quality statistics:

1. How are you going to maintain the coding quality statistics? I

Rewards, etc.

1. How are you going to reward your team, think about what incentives you appreciate at your current position or a previous position.