Title: DQ Guidance DQ – Coding Summary Audit Session : W-6-1630

1. Title: DQ Guidance DQ – Coding Summary AuditSession: W-6-1630

2. Objectives Provide overview of the DQMC Coding Summary Audit Template Demonstrate the DQMC Coding Summary Audit Template Describe how to complete DQMC Commander’s Statement Medical Record Coding Audit comments

3. Background Coding Compliance has been Navy Medicine’s #1 priority for many years In 2010, BUMED M3/5 (HIM) published Standard Coding Audit Guidelines BUMED M84 (DQMC) developed an Excel template to facilitate the collection and reporting of DQMC audits using the standard forms created by BUMED M3/5 in the guidance Navy Medicine DQMC started using this template in the summer of 2010, and continues to use it in FY11

4. Purpose To provide a summary of command level coding audits that use a standardized auditing methodology To categorize coding issues using standardized error reason codes specific for each element To facilitate the aggregation of monthly results at a Regional and Navy Medicine level for improved analysis to support decision making processes

5. Demonstration MTF Coding Summary Audit Tool

6. Demonstration Regional Coding Summary Audit Tool

7. DQMC Comments Medical Record Coding Compliance is reported monthly in Question Series 5, 6, and 7 of the CC Statement DQMC Policy Requirement that all non-complaint metrics (<95%) must have a comment Comments are used to communicate issue identification and plan of action for resolution from a command through TMA (and all of the layers in between)

8. Is This an Appropriate Comment? 6b) E&M ERRORS: 99395 (Prev.Med) used versus 99212 (Office Visit). This is not a Prev,Med visit but just a regular established office visit (1 encounter). 99202 used versus 99201. New patient is 3 of 3, and the exam is problem focused (1 encounter). Modifier 25 should be added to the E&M when a procedure is completed during the same visit (1 encounter). Dictation states that this is the 3rd scheduled visit, so E&M office visit code is not needed. 99499 (place holder) should be used since the injection was scheduled (2 encounters for scheduled visits). 99212 used versus 99401 counseling. Counseling codes should be used for overseas screening (1 encounter). 99213 up coded to 99214 – Medical Decision Making is moderate – exam is detailed (1 encounter).

9. Required Comment Format ITEM: 2a, TT# (if applicable), ISSUE: XX% encounters from ER did not meet the 3-day deadline due to staffing issue. CORRECTIVE ACTION: Effective 1 January, temporarily reassign military staff until civilian/contract hiring process can be completed. Correction Date: January DQS.

10. Summary The Coding Summary Audit Template facilitates the aggregation and reporting of standard error codes for issue identification and resolution. It is critical to provide appropriate comments in support of non-compliant medical records coding audit questions on the monthly DQMC Commander’s Statement.

11. Q&A Questions?