CONDUCTING A CODING PROCESS INVENTORY TO ASSIST ACTIVITIES

Transcription

1 1 CONDUCTING A CODING PROCESS INVENTORY TO ASSIST IN DEFINING YOUR AUDIT ACTIVITIES PRESENTED BY: SHERYL VACCA SENIOR VICE PRESIDENT/CHIEF COMPLIANCE AND AUDIT OFFICER UNIVERSITY OF CALIFORNIA RYAN MEADE MEADE & ROACH, LLP AHIA 31 st Annual Conference August 26-29, 2012 Philadelphia PA

2 Goals 2 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 4. Discuss common deviations from the ideal and audit plan responses Draft

3 3 Integrating the results of a coding process inventory into the auditing plan Traditional coding audit choices: 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 Codes are being chosen closer to (or the same time as) an event Can audits be made smarter by adding process risks to the audit plan?

4 Integrating the results of a coding process inventory into the auditing plan 4 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 plans, process should also be considered

5 Integrating the results of a coding process inventory into the auditing plan 5 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

6 Integrating the results of a coding process inventory into the auditing plan 6 A coding gprocess inventory uses an ideal coding 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 Identify the point a code is chosen and who chooses the code

7 Defining an Ideal Coding Process Flow 7 Important Notes: An ideal coding process flow does not guarantee error-free results, rather it sets out a process which best manages coding selection risk Not having the d ideal coding process flow does not mean a site has errors, but it suggests where not-for cause auditing should occur Draft

8 Ideal Coding Process Flow 8 We propose the following as the ideal coding process flow: a certified coder reviews documentation of a clinical event and chooses codes from the documentation ti bf before a charge posts to a claim. Draft

9 Is the ideal realistic? 9 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 The culture of EMR is to let the system do it The ideal is considered a luxury by many organizations Single greatest trend: Physicians choosing codes

10 Steps in an Ideal Coding Process Flow 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 for processing.

11 11 Ideal Coding Process Flow

12 Top Items Which Introduce Risk into Coding Process Flow Reliance on physician py to choose code. 2. The charge posts to patient s account at time of order/scheduling. d 3. Hospital coding and Physician coding offices do not coordinate. 4. Code checking occurs electronically and certified coders only look at codes on an exception basis.

13 Ideal Flows in Hospital Setting 13 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 are separate

14 14 Ideal When Hospital & Physician Coding Function is Unified

15 15 Ideal When Hospital & Physician Coding Offices are Separate

16 Ideal Flows in Three Other clinical areas 16 Pharmacy Lab Imaging

17 Ideal Coding Flow for Pharmacy Important t features for managing coding risk: Drug not charged until administered Coding occurs after administration 17

18 Ideal Coding Flow for Lab Important features for managing coding risk: Physician does not provide ICD-9 code but writes out diagnosis or reason for test Charges do not post upon order or specimen gathering Blood draw stations do not use previous visit information Coding based on test performed 18

19 Ideal Coding Flow for Imaging Important features for managing coding risk: Coding and charges do not occur until after radiologist reads report Natural language software is audited 100% checked until there are proficiency i tests developed and met Well suited for coding hospital and professional services at same time 19

20 Conducting the coding process 20 inventory 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? 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?

21 7 Observations on Coding Process Flow Risks An EMR should not be assumed to directly assist in managing coding risks. 2. There is a trend nationally to rely heavily upon physicians to choose codes in the EMR or on paper encounter forms. 3. The decision i 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 more auditing the greater the number of people coding

22 7 Observations on Coding Process Flow Risks 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

23 7 Observations on Coding Process Flow Risks 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 predesigned paper encounter forms.

24 24 Some suggestions for audit response to common coding process inventory results Response will be unique to organization, but common needs at health h 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 s proficiency level is reached. 2. A hospital s strategy t for facility E&M codes should be examined to ensure there is a hospital-wide consistent approach among clinical departments..

25 Suggestions for Coding Audits (General) 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. 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 not as ordered or the test may be canceled

26 Suggestions for Coding Audits (General) Service areas that have auto-populate p and/or copy and 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 decisions close to the clinical event

27 Suggestions for Coding Audits (General) 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 what is the process physicians i use?

28 Take-away Points 28 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 Auditing plans need to stay abreast of changing coding processes and incorporate the process flow changes into their audit plan A coding gprocess inventory identifies when a code is chosen and who chooses the code in order to inform smarter auditing

29 29 QUESTIONS? Presenters Contact Information: Sheryl Vacca Ryan Meade

30 Save the Date: August 25-28, nd Annual Conference Chicago, IL 30