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

2010 UBO/UBU Conference

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

Date: 23 March 2010

Time: 1610–1700

2009 UBO/UBU ConferenceTurning Knowledge Into Action

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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

2009 UBO/UBU ConferenceTurning Knowledge Into Action MHS Coding Data Flow – Office Visit

How the usual office visit code flows to the central repository

Book appointment Mark appointment as kept

Conduct encounter Document encounter

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

Codes flow to CHCS

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MHS Coding Data Flow – Ambulatory Procedure

How the usual ambulatory procedure visit code flows to the central repository

Book appointment Mark appointment as kept

Do procedure Dictate operative report

Coder codes in ambulatory data module of CHCS

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


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MHS Coding Data Flow – Inpatient Institutional

How the usual inpatient hospitalization codes 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


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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

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2009 UBO/UBU ConferenceTurning Knowledge Into Action MHS Coding Audit of FY2007 Records

Audit Type of Record

Source of Record Service Number in Sample

Annual SIDR Inpatient Army 700

Annual SADR Outpatient, Non-APV Army 700

Annual SADR APV Army 700

Annual SIDR Inpatient Navy 700

Annual SADR Outpatient, Non-APV Navy 700

Annual SADR APV Navy 700

Annual SIDR Inpatient Air Force 700

Annual SADR Outpatient, Non-APV Air Force 700

Annual SADR APV Air Force 700

MERHCF SIDR Inpatient MHS wide 400

MERHCF SADR Outpatient MHS wide 400

11 random samples of FY 2007 medical records drawn from across the direct care system.

Total audit size = 7,100

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Outpatient Response Rates by Bencat

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Perc

ent FY 2006

FY 2007

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Percent of Outpatient Records that Passed the Audit (only includes records that were received)

0%

10%

20%

30%

40%

50%

60%

SADRArmy

SADRNavy

SADR AirForce

APVArmy

APVNavy

APV AirForce

MERHCFArmy

MERHCFNavy

MERHCFAir Force

Percent

FY 2006

FY 2007

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Percent of Failed Outpatient Records with 1 Error

0%

10%

20%

30%

40%

50%

60%

70%

80%

Perc

ent FY 2006

FY 2007

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The Percent of Audited Records that Failed the Audit that had any E&M, Diagnosis, Or Procedure Errors. FY 2007 E&M Errors ICD errors CPT Errors SADR Army 54.46% 39.93% 52.48% SADR Navy 59.42% 35.71% 51.62% SADR Air Force 51.67% 40.15% 46.10% APV Army 0.26% 53.25% 74.03% APV Navy 0.25% 37.88% 80.30% APV Air Force 2.44% 35.56% 83.11% MERHCF Army 50.68% 35.62% 52.05% MERHCF Navy 40.91% 34.09% 59.09% MERHCF Air Force 66.67% 42.86% 42.86%

FY 2006 SADR Army 57.66% 46.40% 41.89% SADR Navy 58.11% 49.55% 41.44% SADR Air Force 53.00% 48.50% 40.00% APV Army 1.28% 59.39% 65.23% APV Navy 0.55% 40.14% 84.98% APV Air Force 0.92% 50.67% 83.78% MERHCF Army 52.94% 49.02% 41.18% MERHCF Navy 54.17% 42.86% 53.06% MERHCF Air Force 43.18% 63.64% 52.27%

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The Most Common E&M Errors In Audited Records That Failed The Audit E&M not

required Established

patient +/- 1 Level Missing support documentation

FY 2007 SADR Army 14.19% 9.90% 7.92% SADR Navy 14.29% 13.64% 9.09% SADR Air Force 10.04% 10.78% 7.81% APV* MERHCF Army 19.18% 10.96% 2.74% MERHCF Navy 4.55% 11.36% 4.55% MERHCF Air Force 21.43% 14.29% 4.76% FY 2006 SADR Army 16.67% 10.36% 5.86% SADR Navy 13.51% 8.56% 8.56% SADR Air Force 13.50% 13.00% 9.50% APV * MERHCF Army 15.69% 11.76% 7.84% MERHCF Navy 8.16% 8.16% 10.20% MERHCF Air Force 4.55% 6.82% 13.64% *Less than 1%

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The Most Common Diagnosis Errors In Records That Failed The Audit Documentation

does not support coded diagnosis

Primary diagnosis not the

reason for the visit

FY 2007 SADR Army 22.11% 3.30% SADR Navy 18.18% 2.60% SADR Air Force 22.68% 1.12% APV Army 27.79% 14.03% APV Navy 22.22% 5.56% APV Air Force 19.78% 8.22% MERHCF Army 23.29% 2.74% MERHCF Navy 22.73% 0.00% MERHCF Air Force 23.81% 2.38% FY 2006

SADR Army 31.98% 6.31% SADR Navy 31.98% 3.60% SADR Air Force 29.00% 5.00% APV Army 35.79% 14.97% APV Navy 21.60% 9.62% APV Air Force 30.89% 10.22% MERHCF Army 29.41% 7.84% MERHCF Navy 16.33% 6.12% MERHCF Air Force 34.09% 6.82%

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The Most Common Procedure Errors In Records That Failed The Audit Missing

Support Documentation

Documentation does not

Support Coded procedure

Sequencing

FY 2007 SADR Army 31.02% 13.53% 6.27% SADR Navy 27.27% 12.99% 3.25% SADR Air Force 18.96% 14.13% 6.32% APV Army 11.95% 25.19% 30.39% APV Navy 7.58% 25.00% 20.71% APV Air Force 5.11% 18.89% 17.11% MERHCF Army 27.40% 5.48% 8.22% MERHCF Navy 36.36% 18.18% 2.27% MERHCF Air Force 19.05% 7.14% 7.14% FY 2006

SADR Army 7.21% 27.93% 3.60% SADR Navy 9.46% 22.97% 2.70% SADR Air Force 11.00% 21.50% 3.50% APV Army 8.88% 28.68% 25.13% APV Navy 5.16% 27.23% 22.30% APV Air Force 11.56% 22.89% 27.78% MERHCF Army 3.92% 35.29% 1.96% MERHCF Navy 10.20% 32.65% 4.08% MERHCF Air Force 15.91% 29.55% 6.82%

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Estimated Percent of Audited SADR and APVs that were Under or Over Coded*.

APV SADR

Not over or under coded*** 67.45% 53.51%

Over coded 6.63% 26.80%

Under coded 7.15% 2.27%

Can not determine** 18.77% 17.42%

* 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.

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Percent of Outpatient Records that Passed the Regular Audit and a 'Billing' Audit

0%

10%

20%

30%

40%

50%

60%

70%

80%

Per

cen

t

Regular Audit

Billing Audit

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Inpatient Audit Response Rates

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Army Navy Air Force MERHCFArmy

MERHCFNavy

MERHCFAir Force

Per

cen

t R

ecei

ved

FY 2006

FY 2007

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The Percent of Inpatient Records that Passed The Audit (only includes records that were received)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Army Navy Air Force MERHCFArmy

MERHCFNavy

MERHCF AirForce

FY 2006

FY 2007

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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.

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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.

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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

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2009 UBO/UBU ConferenceTurning Knowledge Into Action 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

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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

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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.

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2009 UBO/UBU ConferenceTurning Knowledge Into Action References

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

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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)

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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

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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%.

Documents

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