Software Solutions for Managing Coding (Billing) Compliance • Minnette Terlep • Senior Vice President • United Audit Systems, Inc. • 360 Gest Street • Cincinnati, OH 45203 • 513-723-1122, extension 114
Software Solutions for Managing Coding (Billing) Compliance • What is Coding (Billing) Compliance? • Health Insurance Portability and Accountability Act of 1996 Public Law 104-191 (HIPAA)
Software Solutions for Managing Coding (Billing) Compliance • How are hospitals reimbursed for Medicare inpatient services? • Diagnosis Related Groups (DRGs) • ICD-9-CM Coding Classification • Casemix • Blended rate
Software Solutions for Managing Coding (Billing) Compliance • What is Coding Optimization? • DRG 321 Kidney/Urinary Tract Infection W/O CC • DRG 416 Septicemia • DRG 321 rel. wt. .5785 $2,892 • DRG 416 rel. wt. 1.4988 $7,494 • Increase in Payment $4,602
Software Solutions for Managing Coding (Billing) Compliance • Is there proof that unethical coding has occurred? • 1997 Office of Examinations and Inspection Report (OEI-01-97-00010) • 5.2% upcoding in 20 hospital control group compared to • 11.4% upcoding in 50 hospitals with high predicted rate of upcoding
Software Solutions for Managing Coding (Billing) Compliance • Have any hospitals been charged with fraudulent coding and have those charges resulted in monetary settlements? • Louis Weiss Hospital - Chicago, IL • Sharp Healthcare - San Diego, CA • Edgewater Hospital - Chicago, IL
Software Solutions for Managing Coding (Billing) Compliance • What are the HIPAA requirements for monitoring coding (billing) accuracy? • Corporate Compliance Program • HIM Department Compliance Plan
Software Solutions for Managing Coding (Billing) Compliance • What should be included in the HIM Department Compliance Plan? • on-going prebilling monitors of coding (billing accuracy) • documentation of review results
Software Solutions for Managing Coding (Billing) Compliance • What should be included in the HIM Department Compliance Plan? • ongoing inservice education to prevent future errors • reporting of monitor findings upwards through the organization
Software Solutions for Managing Coding (Billing) Compliance • How does the current manual process for selecting coding review cases compare to a computerized process?
Software Solutions for Managing Coding (Billing) Compliance Comparison of Chart Selection Manual Computerized • random • focused • statistically valid random sample
Software Solutions for Managing Coding (Billing) Compliance • Chart Selection • Focused • DRG • Physician • Coder • High-risk Coding Indicator DRGs • Algorithms
Software Solutions for Managing Coding (Billing) Compliance • Chart Selection • Algorithms • DRG • Diagnoses/Procedures • Length of Stay • Discharge Disposition • Admission Source • Total Charges
Software Solutions for Managing Coding (Billing) Compliance • Statistically Valid Random Sampling • RAT-STATS Methodology • Other statistically valid sampling techniques
Software Solutions for Managing Coding (Billing) Compliance • Uses of Statistically Valid Random Sampling • Statistically valid chart audit versus ongoing prebilling coding quality monitoring
Software Solutions for Managing Coding (Billing) Compliance • How does the current manual process for performing chart review compare to a computerized process?
Software Solutions for Managing Coding (Billing) Compliance Comparison of Review Process Manual Computerized • re-code records • re-code using software clinical reference tools to support potential code changes
Software Solutions for Managing Coding (Billing) Compliance • Computerized Review Process • Clinical Reference Tools • Diagnoses/Procedures descriptions • Official Coding Guidelines • Coding Clinic Publication - AHA • High-risk Coding Indicator DRGs • Expert review recommendations • Coding policies and procedures
Software Solutions for Managing Coding (Billing) Compliance • How does the current manual process for documenting coding review findings compare to a computerized process?
Software Solutions for Managing Coding (Billing) Compliance Comparison of Review Documentation Process Manual Computerized • enter code changes • enter code changes on paper worksheet into log entry screen • hand-write reasons • select causes for for code changes code changes from menu
Software Solutions for Managing Coding (Billing) Compliance Comparison of Review Documentation Process Manual Computerized • enter DRG change • enter DRG change • calculate payment • system calculates change payment change • document other • select other data • information free form to be entered from menu selections
Software Solutions for Managing Coding (Billing) Compliance • How does the current manual process for calculating accuracy rates compare to a computerized process?
Software Solutions for Managing Coding (Billing) Compliance Comparison of Calculating Accuracy Rates Manual Computerized • count total cases • select criteria* from menu for calculating accuracy rates • count # DRG errors • count # codes assigned
Software Solutions for Managing Coding (Billing) Compliance What is included in report criteria*? • Date Range • Coder(s)/Department • Physician • Payor(s) • Reviewer(s)
Software Solutions for Managing Coding (Billing) Compliance Comparison of Calculating Accuracy Rates, con’t. Manual Computerized • count total cases by coder • count # DRG errors by coder
Software Solutions for Managing Coding (Billing) Compliance Comparison of Calculating Accuracy Rates, con’t. Manual Computerized • count total codes assigned by coder • count total coding errors
Software Solutions for Managing Coding (Billing) Compliance Comparison of Calculating Accuracy Rates, con’t Manual Computerized • enter counts into spreadsheet software
Software Solutions for Managing Coding (Billing) Compliance Comparison of Calculating Accuracy Rates, con’t. Manual Computerized • perform calculations of accuracy rates on spread- sheet
Software Solutions for Managing Coding (Billing) Compliance Comparison of Calculating Accuracy Rates, con’t. Manual Computerized • create graphs/reports • print graphs and • print graphs and reports reports
Software Solutions for Managing Coding (Billing) Compliance • How does the current manual process for trending underlying cause of coding error compare to a computerized process?
Software Solutions for Managing Coding (Billing) Compliance Trending Underlying Cause of Coding Error Manual Computerized • analyze free • select criteria* for form text from reporting worksheets underlying causes of coding error
Software Solutions for Managing Coding (Billing) Compliance What is included in report criteria*? • Date Range • Coder(s)/Department • Physician • Payor(s) • Reviewer(s)
Software Solutions for Managing Coding (Billing) Compliance Comparison of Calculating Accuracy Rates, con’t. Manual Computerized • count total cases by coder • count # underlying causes of coding error by coder
Software Solutions for Managing Coding (Billing) Compliance Comparison of Calculating Accuracy Rates, con’t Manual Computerized • enter counts into spreadsheet software
Software Solutions for Managing Coding (Billing) Compliance Comparison of Calculating Accuracy Rates, con’t. Manual Computerized • perform calculations of underlying cause rates on spreadsheet
Software Solutions for Managing Coding (Billing) Compliance Comparison of Calculating Accuracy Rates, con’t. Manual Computerized • create graphs/reports • print graphs and • print graphs and reports reports
Software Solutions for Managing Coding (Billing) Compliance • How can national coding indicator benchmarks be used to evaluate hospital coding accuracy?
Software Solutions for Managing Coding (Billing) Compliance • MedPar Billing Data • Regional Billing Data • Inclusion of national/regional norms • High-risk indicators
Software Solutions for Managing Coding (Billing) Compliance • Examples of Coding Indicators: • CC DRG% n “CC” DRGs X 100 = CC DRG% n “CC” & n “ no CC”DRGs
Software Solutions for Managing Coding (Billing) Compliance CC DRG%: FY ‘97 HCFA National Norm 81.8% FY ‘98 HCFA National Norm 80.3% Decrease 1.5%
Software Solutions for Managing Coding (Billing) Compliance • Examples of Coding Indicators: • Gram-negative to Simple Pneumonia n DRGs 79/80/81 X 100 = ratio of sum (n DRGs 79/80/81 gram-negative + n DRGs 89/90/91) to all pneumonia DRGs
Software Solutions for Managing Coding (Billing) Compliance Gram-negative to All Pneumonia FY ‘97 HCFA National Norm 33.5% FY ‘98 HCFA National Norm 27.6% Decrease 5.9%
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