Revenue Integrity Boot Camp. Coding. Agenda

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1 Annie Lee Sallee MBA, RHIT, CPC, CPMA AHIMA Approved ICD-10-CM/PCS Trainer Revenue Cycle Education Specialist Home Town Health Jenan Custer CPC, CCS AHIMA Approved ICD-10-CM/PCS Trainer and Ambassador Director of Healthcare and Consulting Services (HCCS) Revenue Integrity Boot Camp Agenda Defining Standards Provisional or Concurrent DRG Assignment Productivity Standards Define takeaways Ready, set, Drill Time! 2 Warm up time! Home Town Health Drill Instructor Creed These recruits are entrusted to our care. We will train them and share our knowledge. We will provide all the tools from a coding aspect to help develop a disciplined and fit Revenue Integrity Process. The recruits will be fully indoctrinated in all things coding. We will demand of them and demonstrate by our example, the highest standards of professional skill set. 3 1

2 Standards 4 Standards Inpatient Discharge Summaries and OP note best practices Querying 5 Standards Same Day Surgery OP note Hard coded vs. soft coded 6 2

3 Standards Observation ED to OBS Injections and Infusions Modifiers 7 Standards Emergency Department /Charging ED Admissions ED discharges Modifiers, who is doing what Charge entry, stream lining processes Looking at what is being hard coded Communication of documentation issues Compliant Querying 8 CDI/ Standards Outpatient Lab/RAD coding Compliant orders What about the reports? Thinking about reimbursement from other physicians (i.e. Radiologists) Other documentation (i.e. nursing) Knowing your rules and guidance 9 3

4 Standards PRO FEE side coding Physician participation (or presence) Mid-level involvement Signature requirements Documentation completion 10 Standards AHIMA Standards of Ethical professionals should: Apply accurate, complete, and consistent coding practices for the production of high-quality healthcare data. Report all healthcare data elements (e.g. diagnosis and procedure codes, present on admission indicator, discharge status) required for external reporting purposes (e.g. reimbursement and other administrative uses, population health, quality and patient safety measurement, and research) completely and accurately, in accordance with regulatory and documentation standards and requirements and applicable official coding conventions, rules, and guidelines. American Health Information Management Association Standards of Ethical. (2008, January 1). Retrieved February 26, 2015, from 11 Standards AHIMA Standards of Ethical Assign and report only the codes and data that are clearly and consistently supported by health record documentation in accordance with applicable code set and abstraction conventions, rules, and guidelines. Query provider (physician or other qualified healthcare practitioner) for clarification and additional documentation prior to code assignment when there is conflicting, incomplete, or ambiguous information in the health record regarding a significant reportable condition or procedure or other reportable data element dependent on health record documentation (e.g. present on admission indicator). Refuse to change reported codes or the narratives of codes so that meanings are misrepresented. Refuse to participate in or support coding or documentation practices intended to inappropriately increase payment, qualify for insurance policy coverage, or skew data by means that do not comply with federal and state statutes, regulations and official rules and guidelines. American Health Information Management Association Standards of Ethical. (2008, January 1). Retrieved February 26, 2015, from 12 4

5 Standards AHIMA Standards of Ethical Facilitate interdisciplinary collaboration in situations supporting proper coding practices. Advance coding knowledge and practice through continuing education. Refuse to participate in or conceal unethical coding or abstraction practices or procedures. Protect the confidentiality of the health record at all times and refuse to access protected health information not required for coding-related activities ( examples of coding-related activities include completion of code assignment, other health record data abstraction, coding audits, and educational purposes). Demonstrate behavior that reflects integrity, shows a commitment to ethical and legal coding practices, and fosters trust in professional activities. American Health Information Management Association Standards of Ethical. (2008, January 1). Retrieved February 26, 2015, from 13 CDI/ Standards Source Guidance (naming a few) AHA Clinics CPT Assistants CMS and Local FI/MACS Desk Reference (CM/PCS/CPT) ICD-9/10 CM and PCS Guidelines CPT Guidelines 14 Standards Credentials (naming a few) CCA (AHIMA) CCS (AHIMA) CCS-P (AHIMA) RHIT (AHIMA) RHIA (AHIMA) CPC-A (AAPC) CPC (AAPC) CPC-H (AAPC) Why they are important in Standards 15 5

6 Standards Standards: Credentialed Coders Why they are important in Standards Quality data More accurate payments Compliant A better understanding of new procedures Improved disease management correct code capture Fewer miscoded, rejected, and improper reimbursement claims A better understanding of health outcomes Continuum of education through credentials 16 Work it out!! 17 Provisional or Concurrent Admission Concurrent Discharge 18 6

7 Provisional or Concurrent Let s discuss the types of coding Admission Concurrent Retrospective 19 Provisional or Concurrent What is concurrent coding? What are the benefits? 20 Provisional or Concurrent The Anticipated DRG will drive: - Plan for Stay - Plan for Anticipated Date of Discharge (based on GLOS) 21 7

8 Provisional or Concurrent According to a recent CDI poll on the ACDIS website, only 13% of nearly 170 respondents perform concurrent coding at their facility. The bulk of respondents (50%) indicated they do some concurrent coding primarily in order to assign a working MS-DRG, but coders perform coding retrospectively 22 Provisional or Concurrent Challenges of Concurrent Requires additional staff (CDI/) 23 DRG Assignment 24 8

9 DRG Assignment Diagnosis-related group (DRG) is a system to classify hospital cases. Factors that affect the cost of delivering care: Severity of illness Risk of mortality Prognosis Treatment difficulty Need for intervention Resource intensity 25 DRG Assignment Classified by up to 8 diagnoses in addition to the primary diagnosis & up to 6 procedures performed during one stay as well as patient demographics. Reimbursement PPS: Reimbursed at a fixed rate based on DRG. CAH: Reimbursed at 101% of reasonable cost for facility charges. IP claims reimbursed at charges x interim rate after deductible and coinsurance. CAH fully cost reimbursed on cost report settlement. DRG Assignment Why are DRGs important to CAHs? DRGs = ICD-9 diagnoses & procedure codes Charges = Revenue codes & HCPCS/CPT codes as well as ICD-9 procedure codes 27 9

10 CDI/ Uses of DRGs Reimbursement Evaluation of quality of care Evaluation of the utilization of services Diagnoses support medical necessity and gives the entire reason for why a patient is at your facility to 28 begin with. 29 Why is productivity standards so important? 30 10

11 Inpatient Industry standard Types of IP coding CMI and why it is important Variances in systems Variances in HD versus Low dollar Querying impacts 31 Same Day Surgery Industry standard Types of SDS coding Variances in systems Variances when looking at hard vs. soft coding Querying impacts 32 Observation Industry standard Types of OBS coding Variances in systems Variances when looking at hard vs. soft coding Charge entry Querying impacts 33 11

12 Emergency Department Industry standard Types of ED coding Variances in systems Variances when looking at hard vs. soft coding Charge entry 34 Outpatients Lab/RAD coding Industry standard Types of OP coding Variances in systems 35 Professional Industry standard Types of Professional service E/M, Surgical, Pathology, Radiology, Diagnostic tests or medical services Charge Lag Variances in systems Charge entry vs. Code extraction/documentation completion 36 12

13 Benchmark survey Benchmark surveys with frequency Communicating the benchmark survey findings 37 Impacts Data Entry requirements Abstracting requirements Systems Pending Excessively Questions to ask 38 Tracking time 39 13

14 40 Tracking daily Date: Number Coded Time Spent (total hours/minutes) Inpatient Coded SDS Coded Observation Coded Emergency Department Coded Ancillary Records Coded 41 Cool Down 42 14

15 Defining Takeaways 43 Defining Takeaways Standards Establish ground rules by chart type State the mission to all stakeholders Identify coding requirements Look at current processes and identify barriers Collect data Identify possible solutions by brainstorming Make changes in your coding process! 44 Defining Takeaways Provisional/Concurrent See if concurrent is right for your facility Do you have the resources Is there benefits your facility can obtain with concurrent coding 45 15

16 Defining Takeaways DRG Assignment Understand the purpose and uses of DRGs Ensure proper diagnosis coding 46 Defining Takeaways Productivity Identify current process Benchmark Consolidate tasks and responsibilities Identify opportunity areas Define Standards to staff Define who monitors weekly/daily Reiterate quality standards 47 Learning Outcomes Defining Standards Provisional or Concurrent DRG Assignment Productivity Standards Define takeaways 48 16

17 CDI/ READY. SET. LET s DRILL!! 49 QUESTIONS? Home Town Health Drill Instructor Creed These recruits are entrusted to our care. We will train them and share our knowledge. We will provide all the tools from a coding aspect to help develop a disciplined and fit Revenue Integrity Process. The recruits will be fully indoctrinated in all things coding. We will demand of them and demonstrate by our example, the highest standards of professional skill set

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