JACS Cancer Hospital
HIM Project Improvement Team
Julie Callahan, Ashley Diebler, Casey Wilson, Sabrina Chapman
Mission Statement
• To evaluate the current organizational
coding processes to determine
improvement measures and to initiate a
compliance plan that will ensure our
healthcare professionals, clients, thirdparty payers, and other stakeholders
are provided with the most accurate
and complete billing, as well as data
collection/storage/retrieval services.
Vision
• To be the region’s leader in accurate
and complete health information
management services, who upholds the
highest ethical and legal standards, by
following all HIPAA and state laws.
Values
• Accuracy
• Granularity
• Comprehensiveness
• Precision
• Consistency
• Relevancy
• Accessibility
• Timeliness
• Currency
• Ethicality
• Definition
Goals
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Establish ongoing monitoring to identify problems or opportunities to
improve quality of coded data
Make recommendations for improvement in the Coding Compliance
Plan
Optimize the coding process
Identify variations in coding practices among staff members
Determine cause and scope of identified problems
Set priorities for resolving identified problems
Implement mechanisms for problem-solving through approval of
corrective action plans
Ensure that corrective action is taken by following up on problems with
appropriate monitors
Ensure compliance while meeting organizational needs
Assess for quality health information management & risk management
Decrease over-utilization for healthcare services
Use a database management software application to demonstrate the
use of database technology for collection storage and retrieval of
healthcare data to support ongoing quality assessment
Customers/Stakeholders and
Customers’ Requirements
• Healthcare professionals
• Patients
• Third-party payers
• Registries
• Administration
Provide the most up-to-date and accurate codes for health
records. In order to submit claims that provide the most
appropriate reimbursement.
Quality Assessment
• Audited 30 patient health records with
previous code assignments to ensure
all codes were up-to-date, correctly
assigned, and that no codes were
missing.
Quality Assessment Tools
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Brainstorming
Check sheets
Emails
Discussion boards
Graphs
Excel spreadsheets
PowerPoint
Quality Improvement Measures
• Coding accuracy classified as:
– Correct
– Wrong
– Missing
– Extra
Compiled Data Spreadsheet
Type of Coding System Used
526 Total Codes
(526 total)
5.89%
7.98%
ICD-9 Diagnosis (321)
8.17%
CPT E/M (89)
CPT Pathology (43)
CPT Procedure (42)
16.92%
61.03%
ICD-9 Procedure (31)
ICD-9 Diagnoses Codes
Audit Results (321 Total Codes)
ICD-9 Procedure Codes
Audit Results (31 Total Codes)
CPT Procedure Codes
Audit Results (42 Total Codes)
CPT Pathology Codes
Audit Results (43 Total Codes)
CPT E/M Codes
Audit Results (89 total Codes)
Total Number of Codes
Audit Results
(526 total)
0.95%
15.78%
Correct (394)
8.37%
Wrong (44)
Missing (83)
Extra (5)
74.90%
Audit Results of Records
159 Total Records Audited
13 Records with Deficiencies
(159 total)
7
Number of Records
6
5
4
3
2
1
0
Wrong Dates (1.26%) Missing Dates (3.77%)
Record Status
Were Never Coded
(2.52%)
Incomplete Records
(0.63%)
Correct Codes by Coding System
Wrong Codes by Coding System
(44 total)
0%
11%
ICD-9 Diagnosis (22)
12%
CPT E/M (12)
50%
CPT Procedure (5)
ICD-9 Procedure (5)
CPT Pathology (0)
27%
Missing Codes by Coding System
(83 total)
2% 2%
4%
4%
ICD-9 Diagnosis (73)
CPT E/M (3)
CPT Procedure (3)
CPT Pathology (2)
ICD-9 Procedure (2)
88%
Extra Codes by Coding System
(5 total)
20.00%
CPT Procedure (4)
ICD-9 Diagnosis (1)
ICD-9 Procedure (0)
80.00%
CPT Pathology(0)
CPT E/M (0)
Recommendation for Improvement
• Coding Compliance Plan
• Policies and procedures related to:
– Documentation Standards
– Documentation Guidelines
– Resources all coders should have
– Internal audit process
– Physician query process
– Education and training
– Identify risk areas related to coding
– Corrective Action
– Reporting of compliance issues
Quality Improvement Measure:
Documentation Standards
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Accuracy
Comprehensiveness
Consistency
Accessibility
Currency
Definition
Granularity
Precision
Relevancy
Timeliness
Legibility
Authenticity
Approved format
Policies/procedures
• Record should be organized
systematically
• Only authorized individuals
should document, receive,
and transcribe
• Authors should be clearly
identified
• Use only approved
abbreviations/symbols
• All entries should be
permanent
• Errors should be corrected
in appropriate fashion
• Use addendums to correct
or add info.
• Training/education
• Structured data in EHR
Quality Improvement Measure:
Resources for Coders
• AHIMA’s Standards of Ethical Coding
• CMS and AHIMA’s Official Coding Guidelines &
requirements
• Facility-based coding guidelines
• Any state-specific requirements
• Website access to LCDs and NCDs
• Updated code books
• NCCI edits
• Coding Clinics
• CPT Assistant
• A medical dictionary
• A pharmacology reference
• An anatomy/physiology reference
Quality Improvement Measure:
Internal Audit Process
• Internal audits conducted weekly
• If 10% or greater of submitted claims get denied  conduct
internal audits daily until % of denial is 5%
– HIM coding manager or supervisor will perform internal
audits using claim analysis checklist
• Random selection of 5 records per coder will be audited
• Random selection of 10 records per federal payer and 5
records per physician will be audited
• All trends and coding errors analyzed to determine reason for
coding errors
• Audit results presented to coding staff, supervisors, physicians,
and corporate compliance officer
• Coders to maintain accuracy of 100% or greater
– Below 100%  subject for review and/or corrective action
• Revisions to policies/procedures and systems edits; additional
education/training; disciplinary action
Quality Improvement Measure:
Query Process
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Query when documentation fails to meet the following criteria
regarding any significant reportable condition/procedure:
– Legibility
– Completeness
– Clarity
– Consistency
– Precision
– **Do NOT question a provider’s clinical judgment
Query should include all appropriate information according to form
Query should follow facility-approved query form
Query should be in a timely manner whether concurrent,
retrospective, post-bill design, or a combination of the three
Providers response is required within 48 hrs. Consequences for
noncompliance
Providers response documented in progress note, discharge
summary, or query as part of the formal health record.
Quality Improvement Measure:
Education and Training
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Provided for
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Form:
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Physicians
Coders
Clinical documentation specialists
Other ancillary departments (Case management, wound care, laboratory,
nutrition, etc.)
Webinars: provide reliable, expert, and timely information
Audio seminars
Online education
In-class
Topics:
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AHIMA
ICD-10-CM
EHR Implementation
American Recovery & Reinvestment Act of 2008
Recovery Audit Contractors (RACs)
Quality Improvement Measure:
Risk Areas Related to Coding Issues
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Only bill for items/services actually rendered
DO NOT upcode to enhance reimbursement
DO NOT unbundle to enhance reimbursement
DO NOT bill for discharge when a transfer occurred
DO NOT bill for outpatient services rendered with
inpatient stays if follows 72-hr window rule
DO NOT assign codes resulting in DRG with higher
payment if not supported by documentation (DRG Creep)
DO NOT make code selection on radiology, laboratory, or
any other diagnostic test result
ALWAYS follow coding guidelines unless payer specifies
otherwise in writing and are approved by HIM manager
ALWAYS read ALL clinical documentation
ALWAYS query physician when documentation is unclear
Quality Improvement Measure:
Corrective Action
• Corrective actions for resolving problems
identified during coding audits include:
– Revisions to policies and procedures
– Process improvements
– Education of coders, physicians, and/or
organizational staff depending on the nature of
the identified problem
– Revision or addition of routine monitoring
activities
– Revisions to the chargemaster
– Additions, deletions, or revisions to systems edits
– Documentation of improvement strategies
– Disciplinary action
Quality Improvement Measure:
Reporting of Coding Compliance Issues
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All employees are required to promptly report any good faith belief of a
violation of the laws and regulations that govern JACS Cancer Hospital
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No employee will suffer any penalty or retribution for reporting in good
faith any suspected misconduct or noncompliance
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Any employee who fails to report knowingly suspected misconduct or
noncompliance may be subject to disciplinary action
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Any employee who purposely makes a knowingly false accusation will
be subject to appropriate discipline
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Compliance concerns may be reported to the department supervisor,
manager, or compliance officer either orally or written
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Individuals may also report anonymously at the JACS hotline which is
open 24 hours a day and 7 days a week
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All reports will be referred to the compliance department
Benefits of Coding Compliance Plan
• Improved coding accuracy • Relevant physician and
coder education
• Decrease in denials
• Improved physician
documentation
• Proactive research into
variations from
benchmark data and their
underlying causes
• Timely identification,
correction, and prevention
of potential coding
compliance risks
References
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Johns, M. L. (2011). Health information management technology: An applied
approach. (3rd ed.). Chicago, IL: AHIMA.
Schraffenberger, L. (2012). Basic ICD-10-CM/PCS and ICD-9-CM coding.
Chicago, IL: AHIMA.
Schraffenberger, L. A. & Kuehn, L. (2011). Effective management of coding
services. (4th ed.). Chicago, IL: AHIMA.
Shaw, P. L. & Elliott, C. (2012). Quality and performance improvement in
healthcare: A tool for programmed learning. (5th ed.). Chicago, IL: AHIMA.
Smith, G.I. (2012). Basic current procedural terminology and HCPCS coding.
Chicago, IL: AHIMA.