Briefing: 2008-9 MTF Coding Audit Results for FY2007 Records

1. Briefing: 2008-9 MTF Coding Audit Results for FY2007 Records Date: 23 March 2010 Time: 1610–1700

2. Objectives • Understand difference for data flow for different types of encounters (and who is doing the initial coding) • Know the methodology of the audit • Be aware of the errors which were frequently identified

3. MHS Coding Data Flow – Office Visit • How the usual office visit code flows to the central repository Book appointment Mark appointment as kept Document encounter Conduct encounter Codes flow to CHCS Provider codes encounter in AHLTA Codes flow to and are checked by Coding Compliance Editor (CCE) Fixed codes flow to CHCS, become a CAPER and flow to the MDR and M2 Data for logical evidence based decision making

4. MHS Coding Data Flow – Ambulatory Procedure • How the usualambulatory procedure visit code flows to the central repository Book appointment Mark appointment as kept Do procedure Dictate operative report Codes flow to and are checked by Coding Compliance Editor (CCE) Coder codes in ambulatory data module of CHCS Fixed codes flow to CHCS, become a CAPER and flow to the MDR and M2 Data for logical evidence based decision making

5. MHS Coding Data Flow – Inpatient Institutional • How the usualinpatient hospitalizationcodes flows to the central repository Write admission order Enter admission data in CHCS Discharge patient Dictate discharge summary Inpatient coder abstracts inpatient record Coder enters codes in Coding Compliance Editor (CCE) which checks coding. Coder selects type of DRG. Codes flow to CHCS, become a SIDR and flow to the MDR and M2 Data for logical evidence based decision making

6. MHS Coding Audit Methods • Collected a random sample from all complete SIDR/SADR for encounters done 30 Sep 2006-1 Oct 2007 • Trained coding auditors followed MHS specific coding guidelines • QA audits were done to ensure uniform application of coding guidelines

7. MHS Coding Audit of FY2007 Records 11 random samples of FY 2007 medical records drawn from across the direct care system. Total audit size = 7,100

15. Estimated Percent of Audited SADR and APVs that were Under or Over Coded*. * Based on the type of error found in the record. ** Insufficient documentation was provided *** Includes some records which failed the regular audit, but which were not over or under coded.

19. MTF Coding Audit Study APVs Most common errors in records that failed APVs: • Sequencing of CPT • Documentation does not support coded I-9 • CPT used does not support documentation • Anesthesia not coded • Missing supporting documentation • Institutional fee (99199) not coded These account for approximately 75.2% of APV errors.

20. MTF Coding Audit Study Outpatient Most common errors in records that failed Outpatient: • Documentation does not support coded I-9 • CPT codes used do not support documentation (wrong code) • Missing supporting documentation for CPT (nothing to back up code) • E/M code not required but coded • Missing supporting documentation for I-9 These account for approximately 56% of Outpatient errors. Another 13% had no diagnosis coded, procedure or service not coded, wrong category of E/M, CPT sequencing or primary diagnosis not the reason for the visit.

21. MTF Coding Audit Study Inpatient Most common errors in records that failed Inpatient: • Missing supporting documentation for I-9 • Diagnosis not coded • DRG assignment error • Order of Diagnosis not addressed These account for approximately 50% of Inpatient errors. Another 30% had missing supporting documentation for CPT codes, complications and co-morbidities not coded, documentation does not support coded diagnosis

22. MTF Coding Audit Study Some specifics where coding errors were: • Review Coding Guidelines for sequencing, both CPT and I-9 • Review coding guidelines for screening exams specifically that regardless of the findings or if any procedure is performed as a result of a finding, a screening is still a screening. • Correct coding when APV is cancelled prior to start of procedure • Arthroscopic procedures, coding for compartments of knee • Removal of pin coded but is bundled into procedure

23. MTF Coding Audit Study Some specifics where coding errors were: • Review Coding Guidelines for sequencing, both CPT and I-9 • Review coding guidelines for screening exams specifically that regardless of the findings or if any procedure is performed as a result of a finding, a screening is still a screening. • Correct coding when APV is cancelled prior to start of procedure • Arthroscopic procedures, coding for compartments of knee • Removal of pin coded but is bundled into procedure

24. MTF Coding Audit Study Continued • “Likely” appendicitis can only be coded as abdominal pain; “working diagnosis” probable, etc code to highest degree of certainty. • Documentation states “failed conservative treatment”. . . That would support a degenerative, rather than an acute condition. • Mesh insert documented but not coded • Surgical approach is coded incorrectly; open, laparoscopic • Orthopedic coders should know what a slap lesion is and should be coding it. • Review coding guidelines on when to use E/M, 99499 or procedure. Removal of a mole has a 10 day global period, so the procedure should be coded and 99499 should be used, not an E/M code.

25. References • DoD Coding Guidelines: • http://www.tricare.mil/ocfo/bea/ubu/coding_guidelines.cfm

26. Easy Fixes • Send the documentation – if the printout from AHLTA says “see attached document” send the additional document • Need more than the procedure name to code the procedure • Inpatient – be sure to use the TRICARE DRG • Ambulatory Procedure – • Be sure to code the anesthesia • Sequence the procedure with the greatest weight first (guidance in 2007)

27. Easy Fixes • Document the time in and time out for time-based codes • Consults need a request and written response to the requesting provider • Avoid unbundling • EKGs – need both the tracing and report to code 93000 • Don’t code resolved conditions • Use an External Cause of Injury Code (E-code) for the INITIAL visit due to an injury

28. Summary of Audit Findings • Outpatient response rates have increased, especially for mobile populations. • The pass rate for outpatient records has increased to around 40%. • The majority of failed records have only 1 error. • A higher percentage of outpatient records (especially APVs) passed a billing audit. • Around 27% of SADRs appear to be over coded. • The percent of inpatient records passing the audit increased to around 90%.