Clinical Documentation and Coding: The Way Forward

1. Clinical Documentation and Coding: The Way Forward CAPT Rebecca McCormick-Boyle Assistant Deputy Chief, Current Operations, BUMED M3B

2. The Process: From Clinical Documentation to Decision Making INPUTS Clinical Documentation Coding OUTPUTS Resourcing Population Health & Clinical Quality

3. Clinical Documentation & Coding: Decision Making Examples • Population Health & Clinical Quality • HEDIS Measures • Illness & Injuries Frequency & Trends • Force Health Protection & Readiness • Research • Risk Management • Resourcing • Business Case Analysis • Service Line Development • Manpower Assessment • Funding Review • Equipment Plans • PPS earnings

4. Clinical Documentation & Coding:DQMC Assessment

5. Clinical Documentation & Coding:Recovery Audit Assessement • Financial recapture opportunity: $61M • Relative Weight Products: $26M by standardizing the provider query process and increasing provider and coder communication. • Evaluation and Management coding: $8M in physical exams. • Ambulatory Procedure codes: $27M through placement in the correct Medical Expense and Performance Reporting System • Population health opportunities: • HEDIS/ Population Health: Gestational diabetes vs chronic diabetic • Procedural data: 1000 cc vs. 1 cc of a pharmaceutical product • Procedural data: 900 procedures vs. 1 procedure provided • Procedural data: Abortions - elective vs. spontaneous • Issues: • Training: #1 reason Navy-wide for DQMC coding deficiencies • Staffing: Numbers; coding competency and MATO contract concerns • Process: Adherence to standard coding audit guidelines • Technology: AHLTA’s coding methodology (i.e., specialty care)

6. “Just as a complete and accurate medical record coding promotes quality in healthcare delivery, complete and accurate medical record coding promotes quality and clarity in healthcare cost accountability.” -Surgeon General’s Policy Letter on Coding, 1 Oct 2010 Clinical Documentation & Coding:SG’s Assessment

7. Clinical Documentation & Coding:Action Plan & Guidance Coding Program Standard Audit Guidelines, 23 Feb 10 SG’s coding policy letter, 1 Oct 10 HIM coding guidance letter, 8 Nov 10 Navy Medicine coding survey, 24 Nov 10 Project Management Office, 10 Dec 10 MATO Policy Letter, 10 Dec 10 Audit Registry Prototype Letter, 23 Dec 10 Regional Assessment Letter, 14 Dec 10

8. Clinical Documentation & Coding:Program Management Office Action Steps • Standardize Audit Process • Regional Assessment Visits • Query Process: • Provider – coder communications • Personnel processes • Position Descriptions, Performance incentive, Contracting • Training • Standardized and centralized • E&M Code Guidance • Physical exams in particular (well vs. established)

9. Clinical Documentation & Coding:Recommended MTF Action Steps • Review DQMC and coding processes • Involve clinical and admin leadership in DQMC review • Include PAD officer in the DQMC process • Engage PAD officer in reporting and action planning • Review audit findings (trend analysis) • Increase your audits: • Sample size > 30 minimum • Focused reviews/root cause analysis of DQMC statement error and reason codes

10. Clinical Documentation & Coding:The Goal Decision Making Based on Accurate Data Strong Foundation for ICD-10 Implementation Acknowledge the importance of our clinical staff’s valuable time and effort and our responsibility to invest in the resources needed to capture clinical documentation Enhanced understanding of the health of those we serve