By Lisa A. Eramo
So many coding topics to audit, yet so few staff members to perform those audits. Many coding departments nationwide face this dilemma. How can you ensure that your 2013 audit plan includes inpatient coding topics most relevant to your facility?
The first step is to create a highly structured audit plan, says Julie Daube, BS, RHIT, CCS, CCS-P, manager of coding quality review and education at Care Communications, Inc. in Chicago.
Daube says the audits performed by Recovery Auditors and other external auditors have prompted facilities to adopt audit plans that clearly spell out:
- The MS-DRGs or codes to be audited
- The frequency of the audits
- What the audits will entail
- What steps the facility will take to follow-up with audit results
The next step is to prioritize audit topics, says Daube. “Resources are really hard to come by. You need to prioritize and look at the topics that could affect your facility the most.”
Consider the following questions as you plan inpatient coding audits for the upcoming year:
1. What are your top 10 MS-DRGs? These could be high-volume or high-dollar amount MS-DRGs. How do your top 10 MS-DRGs compare with those your Recovery Auditor is targeting? “You could even expand it beyond your top 10 if you wanted to get a good picture of how your facility is doing. Then compare that to the [Recovery Auditor] list,” says Daube.
2. What does your PEPPER data reveal? The Program for Evaluating Payment Patterns Electronic Report (otherwise known as PEPPER) includes hospital-specific data about MS-DRG outliers that could raise red flags for auditors. TMF Quality Institute, which publishes PEPPER, also provides other resources that can help hospitals develop audit plans. These resources include reports about DRGs at risk for improper payments, top 20 medical DRGs for one-day stays, and top 20 surgical DRGs for one-day stays.
“If you’ve never seen your PEPPER, you need to find out who gets the report so you can review it. It’s invaluable information,” says Daube.
3. Are any of the topics on the 2013 OIG Work Plan relevant to your facility? The 2013 OIG Work Plan includes several new hospital inpatient topics, including:
- Inpatient billing for Medicare beneficiaries,
- MS-DRG window
- Compliance with Medicare’s transfer policy
- Payments for discharges to swing beds in other hospitals
- Payments for canceled surgical procedures
- Payments for mechanical ventilation
All of these topics are certainly audit-worthy, says Daube.
4. Are any of the MS-DRGs targeted for Recovery Auditor pre-payment reviews relevant to your facility? Recovery Auditors are currently targeting the following MS-DRGs in selected states that have high rates of fraud and error (Florida, California, Michigan, Texas, New York, Louisiana, and Illinois) or high volumes of short-stay cases (Missouri, North Carolina, Ohio, and Pennsylvania):
- 312 (syncope and collapse)
- 069 (transient ischemia)
- 377-379 (gastrointestinal hemorrhage with MCC, with CC, or without CC/MCC)
- 637-639 (diabetes with MCC, with CC, or without CC/MCC)
Although the Recovery Auditor pre-payment reviews are part of a demonstration program, these reviews could eventually be rolled out nationwide as part of a permanent program, says Daube.
5. Have internal quality assurance (QA) reviews revealed any patterns of coding errors? If so, these errors may justify more focused reviews as well as individual coder education, says Daube.
6. What feedback can coders provide? What conditions do coders query most frequently, for example? This information can be used in conjunction with more formal electronic health record (EHR) reports to identify potential audit topics, says Daube.
7. How specific is your documentation? No singular audit can prepare facilities for the transition to ICD-10-CM/PCS. Instead, clinical documentation improvement efforts should be ongoing to achieve greater specificity, says Daube.
Pay close attention to cloned documentation in the EHR (i.e., non-specific documentation that is copied and pasted for each patient’s stay), says Lori-Lynne Webb, CPC, CCS-P, CCP, an independent coding consultant located in Melba, ID.
Webb says providers may clone documentation for patients who are in the hospital for extended periods of time as well as those who present frequently to the hospital (e.g., patients who mistakenly believe they are in labor). Coders then assign codes based on this oftentimes vague and non-specific information.
Ideally, documentation should include any new patient-specific information, such as medication changes or any other changes relative to the patient’s improvement or decline, says Webb. Physicians may need to see examples of cloned documentation as well as proper documentation so they know what to avoid, she adds.
8. Is the EHR contributing to coding or other errors? In addition to the problem of coding based on cloned documentation, EHRs may potentially contribute to other coding errors. Webb says she has encountered instances in which the date of admission captured in the EHR doesn’t match the date of the physician’s order to admit the patient.
“There are these glitches that you come across,” she says. “If you’re not really actively looking at it as a coder or auditor, you wouldn’t catch it. The documentation would be totally wrong.”
Webb says the glitches may be software-related, or they could be a result of human error. Either way, these errors could affect payment—and the three-day-window—because it skews dates of service, she adds.
Common trouble spots
Although audit plans will be hospital-specific, many topics will likely appear on most hospitals’ lists in 2013. Daube provides the following examples:
- Excisional debridement. Does documentation include the term excisional as well as specific details of the removal, such as procedure details (e.g., measurement of wound dimensions, type and method of debridement, depth of the wound [subcutaneous, muscle, or bone], and a description of what tissue was removed) and instruments used?
- Lysis of adhesions. Does documentation describe the extensive amount of time and/or energy it takes the physician to remove the adhesions to access the organ? Daube says physicians should document the severity of the adhesions and the time spent to remove them prior to performing the surgery. “It needs to be more extensive than snipping the adhesions or removing them with their fingers,” she says. If this documentation is not present, coders can’t assign a separate code for the lysis of adhesions, as it’s considered part of the procedure.
- DRGs with one CC or one MCC. Does documentation support the assignment of the singular CC or MCC that drives a higher-weighted MS-DRG assignment?
- Acute pulmonary insufficiency after surgery or trauma. Does documentation include the term acute?
- Extensive operating room procedures unrelated to the principal diagnosis (i.e., MS-DRGs 981-983). Are coders correctly assigning the principal diagnoses that drive these MS-DRGs? In some—but not many—cases, these MS-DRGs may actually be appropriate, says Daube. For example, a patient is admitted for pneumonia. While in the hospital, the patient is diagnosed with choleysistitis and undergoes a cholecystectomy. According to the ICD-9-CM Official Guidelines for Coding and Reporting, this will correctly trigger one of these MS-DRGs, says Daube. The procedure (i.e., the cholecystectomy) is unrelated to the principle diagnosis (i.e., the pneumonia).
- Present-on-admission (POA) indicators for hospital-acquired conditions (HAC).“If someone incorrectly assigns the POA indicator, the hospital will potentially receive lesser reimbursement,” says Daube. “This is an easy mistake to make. It could be a careless mistake, but it could cost your facility a lot of money.” She says coders can’t assume that HACs aren’t POA just because physicians may not document them until after admission. Tests that a physician orders on admission may provide clues. When documentation is unclear, coders should query for more information, she adds.
Webb says hospitals should consider auditing for sepsis in 2013 if they aren’t doing so already. Coders can’t code sepsis unless physicians explicitly document the term. They must also query when documentation is unclear or when clinical indicators suggest that the condition may be present but not documented, she adds.
Another potentially audit-worthy topic Webb frequently encounters is diabetes, particularly in patients who are pregnant. Physicians must document whether a patient has pregnancy-induced diabetes or pre-existing diabetes that has been exacerbated by the pregnancy, she adds.
Audits and contract coders
Don’t forget about contract coders as you develop your 2013 coding audit plan. Most contract companies provide internal quality assurance; however, it’s valuable to spot check contract coders’ work periodically, says Daube. “Ultimately, the facility’s money is on the line.”
Editor’s note: Eramois a freelance writer and editor in Cranston, RI who specializes in healthcare regulatory topics, health information management, and medical coding. Email her at leramo@hotmail.com.