DRG Workshop Belgrade, 18-22.November 2013. DRG Workshop 18 – 22 November 2013 Belgrade

DRG Workshop Belgrade, 18-22.November 2013.

DRG Workshop

18 – 22 November 2013Belgrade.


Classifications and codingTuesday, November 19th, 2013


Introduction and overview to clinical classification and

coding


What is clinical coding?

• Translation of narrative text into codes

• Understanding of clinical information

• Understanding of classification system

• Ability to allocate appropriate code(s)

Atrial fibrillation = I48

4


Classification & Nomenclature

Statistical classification:

•Brings together diseases that are similar and groups them under one category or code

•Limited number of categories

Nomenclature:

•Has a separate listing for every condition and therefore a separate code for every disease

•Very extensive and detailed

5


Good clinical coder

• Knowledge of:– Medical terminology– Medical science

• Disease processes• Investigations, treatments and interventions

– Content and structure of clinical record– Understanding of classification system– Understanding of coding rules and standards

6


Why code?

• Provision of database of coded information

• Used for:– Clinical management– Clinical research– Identifying disease trends– Monitoring quality of care

7


Why code?

• Used for cont.:– Funding & financial management– Review resource consumption– Workforce & facilities planning– Setting benchmarks– Comparisons

8


Accurate coding

• Need for accurate coding:

– Ensures information is reliable to use

– Necessary for accurate DRG allocation

9


↓

↓

Abstraction of information from the clinical record

Assignment of ICD-10 and ACHI codes

Assignment of DRG

10


Calculating an AR-DRG: Data Items Required

ICD-10 and ACHI Codes

- Principal diagnosis

- Additional diagnoses, such as complications and comorbidities

- Procedure/s

ICD-10 and ACHI Codes

- Principal diagnosis

- Additional diagnoses, such as complications and comorbidities

- Procedure/s

Mode of separation (discharge status)Includes died, transferred

Mode of separation (discharge status)Includes died, transferred

SexSex

Same-day StatusSame-day Status

Newborn admission weightFor age 28 days or less, plus older if

less than 2500 grams

Newborn admission weightFor age 28 days or less, plus older if

less than 2500 grams

Length Of Stay

Or

Admission and Separation Dates

Length Of Stay

Or

Admission and Separation Dates

11


If it’s not written, it didn’t happen!

• The production of quality clinical data is a collaborative effort

• Channels of communication between clinicians and clinical coders should be open and frequently used

• Quality documentation supports quality coding which results in appropriate DRG allocation

12


Good clinical documentation

The most appropriate DRG can only be assigned to an episode of patient care when relevant clinical information is accurately documented in the clinical record

13


Good clinical documentation cont.

• Need clear and complete documentation

• Important for clinical specialties to understand what information can impact on DRG assignment

14


Dementia – impact on DRG assignmentAge 69 yearsGender MaleDiagnosis Cognitive impairmentPrincipal diagnosis R41.8 Other and unspecified

symptoms and signs involving cognitive functions and awareness

MDC 23 Factors influencing health status and other contacts with health

servicesDRG Z61A Signs and symptomsAR-DRG cost weight 0.67ALOS 2.71 daysReimbursement $2,617

15


Dementia – impact on DRG assignment cont.

Diagnosis Mild cognitive disorderPrincipal diagnosis F06.7 Mild cognitive disorderMDC 01 Diseases and disorders of the nervous

systemDRG B64B Delirium without catastrophic

complication and/or comorbidity

AR-DRG cost weight 1.40ALOS 6.03 daysReimbursement $5,452

16


Diagnosis Cognitive change due to dementiaPrincipal diagnosis F03 Unspecified dementiaMDC 01 Diseases and disorders of the

nervous systemDRG B63Z Dementia and other

chronic disturbances of cerebral function

AR-DRG cost weight 2.70ALOS 12.82 daysReimbursement $10,562

Dementia – impact on DRG assignment cont.

17


Coding process

Abstraction of information•Be aware of potential documentation issues

– Unclear– Incomplete– Missing– Conflicting

18


Coding processAbstraction of information cont.•Review the whole clinical record•Look at

– Discharge information forms– Progress notes– Investigation results– Operation reports– Specialist notes

19


Coding processAbstraction of information cont.•Apply medical terminology and medical science knowledge

•Apply coding rules•Apply coding standards

If you cannot analyse and abstract you cannot code

20


Coding process

• Methodology (used in Australian)– Read the front sheet– Read the discharge summary/letter– Compare Dx on front sheet & Discharge summary– Read history and physical examination– Identify any interventions to be coded– Review entire record

21


Example

Patient presented with rapid onset of dyspnoea and chest pain. A chest X-ray revealed a spontaneous pneumothorax.

22


Coding process

Allocating codes•Methodology

– Identify the statement to be coded & refer to the appropriate Alphabetic index

– Locate the lead term – Follow any notes under the lead term– Read all nonessential and essential modifiers

23


Coding process

Allocating codes cont.•Methodology cont.

– Follow any cross-references– Refer to the Tabular list to verify code– Read and follow any coding notes– Check ACS ▼– Assign the code

24


Accurate inpatient coding

• Correct identification of Diagnoses and Procedures

• Assignment of correct ICD-10 and ACHI codes

• Correct sequence of Pdx

25


Causes of errors• Failure to review the entire clinical record• Failure to abstract the relevant information• Coding not validated by content of record• Selection of the incorrect ICD-10 or ACHI

codes• Sequencing errors • Transposition errors • Poor documentation

26


The International Statistical Classification of Diseases and Related Health Problems, Tenth

Revision (ICD-10)• A three volume clinical classification comprising:

– Tabular List (Volume 1)• Alphanumeric listing of diseases

– Instruction Manual (Volume 2• Introduction, instructions and guidelines for Vol 1 & 2

– Alphabetical Index (Volume 3)• Comprehensive alphabetical index of diseases and

conditions found in the Tabular List27


ICD-10 – Volume 1– ICD-10 is a variable-axis classification

• epidemic diseases

• constitutional or general diseases

• local diseases arranged by site

• developmental diseases

• injuries

– 3 main elements to the structure• 3 volumes

• 22 chapters

• alphanumeric codes

28


ICD-10 – Volume 1

• Tabular List – Volume 1– 22 broad groupings of diseases and injuries

called chapters, I-XXII (roman numerals)

– Within the chapters, codes are divided up into blocks of 3 character categories (usually by site or type of disease)

29


Structure of the ICD-10 code– In ICD-10 the 4 character code consists of

J45.9First

character A to Z

Followed by2 digits

Thena point

LastlyAnother

digit

30


Special groups– The following six chapters are special groups of

diseases and conditions which are not included in the chapters organised by anatomical site

• infections• cancer• pregnancy• newborns• congenital conditions• injuries

– These 6 chapters have priority, have precedence over anatomical site chapters

31


Inclusion Terms– May be listed under block and code titles –

additional examples and synonyms of the diagnoses and diagnostic terms that are classified there

• They do not include every possible diagnosis or term – as a guide only

• Not always in the alphabetic index

32


Exclusion Terms– Found at chapter, block, category or code title

level• Important warnings to coders that if the condition

being coded is listed in the exclusion terms it may not be coded under that code

33


Punctuation[ ] Square brackets – used to enclose synonyms, abbreviations, alternative words( ) Parentheses are used in the normal way to enclose additional information or examples of codes

May be used to enclose nonessential modifiers – the presence or absence of these terms in the diagnosis has no effect on the selection of the code

: Colons – a term in an inclusion or exclusion list followed by a colon means that the term is incomplete{ } Braces – link a series of terms, each of which is modified by the term to the right of the brace

34


Annotations

† Dagger symbol• denotes a code describing the aetiology or

underlying cause of a disease, should always be sequenced with the appropriate manifestation code

* Asterisk symbol• denotes a code describing the manifestation of a

disease and should always be assigned with the appropriate aetiology code

35


Words and abbreviations– NEC Not elsewhere classified

• Used in code and category titles to warn the coder that there may be another, better or more specific code in the classification

• If there is more precise information about the condition, then look for a more specific code

– NOS Not otherwise specified• This means ‘unspecified’ • Codes that contain terms followed by NOS can be used when

there is not enough information to assign a more specific code

36


Words and abbreviations cont.– ‘AND’ in code titles

• In the tabular list of diseases, ‘and’ means ‘and/or’

• This code title means that under H21.3 you can code diagnoses of ‘cyst of iris’ OR ‘cyst of ciliary body’ OR ‘cyst of anterior chamber’ OR a combination of the three

• The use of ‘and’ to mean ‘and/or’ only occurs in the Tabular List (Vol 1)

37


Other and unspecified codes– There is not always a separate heading for each

disease– Most of the codes have 4 characters – a letter, 2

numbers, a decimal point and then another number

– The 4th characters of ‘8’ & ‘9’ are residual codes:.8 = other.9 = unspecified

– You must be directed to ‘other’ and ‘unspecified’ codes by the index

38


Aetiology and manifestation• Known as dagger asterisk system

– For certain conditions, it is important to identify both the aetiology (underlying disease) and the manifestation (resulting condition)

– Provides further information for morbidity coding

G30.0† Alzheimer’s disease with early onset

F00.0* Dementia in Alzheimer’s disease with early onset

Dagger = aetiology

Asterisk = manifestation

39


Alphabetical Index – Volume 2

– Lists diagnostic terms and their corresponding code numbers from the tabular list

– Contains many more terms than those appearing in the tabular list

– Three sections:• Alphabetic index of diseases and nature of injury• External causes of injury• Table of drugs and chemicals

40


Conventions• Lead terms

– main term, first place to look in index, usually the name of a disease or condition, not a site

• Essential modifiers– found under the lead term (subterms), with a hyphen

in front. May be essential modifiers under subterms, down to five indents

• Nonessential modifiers– May be found after a lead term or subterm, in

parentheses ( ). Have no effect on code selection

41


Conventions cont.Lead term Nonessential modifiers

Essential modifier

Sequenced in alphabetic order

42


Coding rules, guidelines and standards

• ICD-10 Volume 2, Instruction Manual– provides a basic description of the ICD– contains rules and guidelines for the use of the

classification for coding of mortality and morbidity data

– contains guidelines for the presentation and interpretation of data

43


Coding rules, guidelines and standards cont.

• Australian Coding Standards– Provide rules, guidelines advice– Assume coder has basic training– Assist with consistency in use and application of

ICD-10-AM and ACHI

44


Australian Classification of Health Interventions – ACHI

•Self-contained classification based on a fee schedule (MBS)

•Numeric codes – five digits with a two digit extension

45


Development of ACHI

• No companion intervention classification with ICD-10

• Need for an intervention classification to accompany ICD-10-AM

• The Medicare Benefits Schedule (MBS):

−a fee schedule

−formed the basis of ACHI

46


Development of ACHI cont.• Features−Meaningful terminology−Staged procedures

−Devices

38430-00 [565] Thoracoplasty, staged, first stage38430-01 [565] Thoracoplasty, staged, second or subsequent stage

35309-08 [754] Open transluminal balloon angioplasty with stenting, single stent

35309-09 [754] Open transluminal balloon angioplasty with stenting, multiple stents

47


Development of ACHI cont.• Features−Laterality

−Codes for procedures commonly performed together

33524-00 [700] Renal endarterectomy, unilateral33527-00 [700] Renal endarterectomy, bilateral

30532-01 [864] Oesophagogastric myotomy, abdominal approach, with closure of diaphragmatic hiatus

49562-02 [1511] Arthroscopic removal of loose body of knee with chondroplasty and multiple drilling or implant

48


ACHI Structure

• Chapters follow the ICD-10 structure as closely as possible

• Anatomical site rather than surgical

49


ACHI Structure cont.• Multi-axial structure−primary axis – site−secondary axis – procedure type−tertiary axis – specific site, procedure or technique

used• Exceptions−dental, obstetrics, radiation oncology, imaging and

miscellaneous procedures

50


ACHI Structure cont.• Primary axis –site

−Order is ‘superior’ to ‘inferior’ or head to toe

approach Orthopaedics

head

sternum and ribs

spine

shoulder

upper arm

51


ACHI Structure cont.• Secondary axis – intervention

least invasive most invasiveExaminationApplication, insertion, removalIncisionDestructionExcisionReduction (in musculoskeletal chapter only)RepairReconstructionRevisionRe-operationOther procedures

52


ExampleConcepts classified first by site (nose) then by

intervention:Examination41653-00 Examination of nasal cavity and/or

postnasal space41764-00 Nasendoscopy

Application, insertion, removal41907-00 Insertion of nasal septal button

Incision41659-00 Removal of intranasal foreign body41683-00 Division of nasal adhesions

Type of procedure

53


ACHI Structure cont.• Numbering system and blocks

−Code numbers not in numerical order

−Block numbers are in numerical order

54


ACHI Structure cont.

• Block numbers (1 - 2016)

−assist users in finding a specific code

−provide the means of easily aggregating certain

types of procedures for data analysis purposes

55


ACHI Structure cont.

• Diagnostic terms generally not included in ACHI descriptions

• Exceptions- when the diagnosis is integral to the procedure being performed

32132-00 [941] Sclerotherapy of haemorrhoids Injection of haemorrhoids

56


Code structure

• No intrinsic meaning in this extension

• When only one concept within an MBS item the extension is 00

36561-00 [1047] Closed biopsy of kidney

57


Code structure cont.

42773-00 Repair of retinal detachment by diathermy

42773-01 Repair of retinal detachment by cryotherapy

The last two characters are allocated for each new procedural concept derived from the MBS item description

The first five characters represent the MBS item number:

42773 Detached retina, diathermy or cryotherapy for

58


Example

16520-00 Elective classical caesarean section

16520-01 Emergency classical caesarean section

16520-02 Elective lower segment caesarean section

16520-03 Emergency lower segment caesarean section

MBS item number

ACHI extension

59


Appendices in ACHI• Appendix A: Mapping table

−Lists all MBS item numbers that have not been

used in the classification and their maps

• Appendix B: ACHI code list

−Complete numerical listing of all ACHI codes and

the corresponding block number

60


Conventions in the Tabular List

• Conventions

−Certain words, symbols and punctuation marks • special meaning • provide guidance in code selection

−Refer to:• Tabular list - Conventions used in the tabular list of

interventions• ACS 0040 - Conventions used in the tabular list of

interventions

61


Conventions in the Tabular List cont.• Most are the same as those used for diseases• New or different:−Includes notes

• refers to inherent procedural components or equipment• further defines the site

−and/or in code titles – ‘and’ means and, ‘or’ means or

59900-00 [607] Left ventriculography59900-01 [607] Right ventriculography59900-02 [607] Left and right ventriculography

62


Structure of ACHI Index• Alphabetical according to main terms−type of procedure−actual name of procedure−eponyms

• Alphabetical sequencing for subterms• Exceptions−The following subterms come first under a main term

63


Structure of ACHI Index cont.


• Alphabetic index in the sectionConventions used in the tabular list of interventions

• ACS 0041 Conventions used in the alphabetic list of interventions

Conventions in the Alphabetic Index


• Same as those used for diseases:−essential and nonessential modifiers−NEC – not elsewhere classified−‘see’ and ‘see also’

• Unique to interventions−See block - you must go to the Tabular List and look at

the codes in the block−Omit code – instruction in index next to procedures

that are an operative approach

Conventions cont.


ACS 0016 General procedure guidelinesACS 0042 Procedures normally not codedACS 0031 AnaesthesiaACS 0020 Bilateral/Multiple proceduresACS 0019 Procedures not completed or

interrupted

General standards for interventions


ACS 0023 Laparoscopic/ arthroscopic/ endoscopic surgery

ACS 0032 Allied health interventionsACS 0038 Procedures distinguished on the basis

of size, time, number of lesions or sites

ASC 0047 Adhesions

General standards for interventions cont.


• A procedure is defined as a clinical intervention represented by a code

• A clinical interventions−is surgical in nature−carries a procedural risk−carries an anaesthetic risk−requires specialised training−special facilities or equipment only available in

an acute care setting

ACS 0016 General procedure guidelines


Ordering of intervention codes1. Procedure performed for treatment of the

principal diagnosis2. Procedure performed for treatment of an

additional diagnosis3. Diagnostic/exploratory procedure related to the

principal diagnosis4. Diagnostic/exploratory procedure related to an

additional diagnosis for the episode of care

ACS 0016 General procedure guidelines cont.


• Do not code clinical interventions−that are routine in the treatment−expected or inherent parts of treatment−Refer to ACS 0042

ACS 0016 General procedure guidelines cont.


• Usually routine in nature• Performed for most patients• Can occur multiple times• Resources often reflected in Dx

ACS 0042 Procedures normally not coded


• Important “Note” at beginning of list−A specialty ACS may override ACS 0042−If performed under GA – must code−Code if procedure is the principle reason for

admission

• Become familiar with this list

ACS 0042 Procedures normally not coded cont.


• If a procedure is started but is interrupted or not completed, code as far as it went:−if only an incision was made, code an incision of the site−if the surgeon entered a body cavity or space, code an

exploration of the site

• ACHI has some codes for ‘failed procedures’

ACS 0019 Procedure not completed or interrupted


• A procedure maybe endoscopically performed or via a traditional incision

• ACHI has codes which differentiate between these

• If no endoscopic code available assign−a code for the specific procedure−a code for the endoscopy

ACS 0023 Laparoscopic/arthroscopic/endoscopic surgery


• If division of adhesions performed, even if part of another procedure

−code the diagnosis of adhesions and

−code the division of adhesions

ACS 0047 Adhesions


• Bilateral procedures−Definition

ACS 0020 Bilateral/multiple procedures

Bilateral procedures are those which involve the same organ/structure on different sides of the body at the same operative episode


• Bilateral procedures−Classification guidelines

• Procedures with a bilateral code e.g. bilateral knee replacementCode once

• Inherently bilateral procedures e.g. tonsillectomyCode once

ACS 0020 Bilateral/multiple procedures cont.

home.hawaii.rr.com/dochazenfield/images/Norma


• Bilateral procedures cont.−Classification guidelines cont.

• Procedures with no code option for bilateral e.g. bilateral fracture wristsCode twice


home.hawaii.rr.com/dochazenfield/images/Norma http://www.matthews.co.nz/images/cataracts.jpg


• Multiple procedures−Definition


ACHI generally refers to organs, diseases and sites using the singular tense. This is done for consistency and ease of updating. For example, the code title intranasal removal of polyp from maxillary antrum includes where one, or more than one, polyp is removed. Thus polyp can be interpreted as polyp or polyps. Other examples include wart(s), skin tag(s), biopsy/biopsies, lesion(s).


• Multiple procedures −Classification guidelines

• The same procedure repeated during the episode of care at different visits to theatre Code as many times as performed

• The same procedure repeated during a visit to theatre involving one entry point/approach and similar/same lesions Assign one code



• Multiple procedures cont.−Classification guidelines cont.

• The same procedure repeated during a visit to theatre involving one entry point/approach and different lesions

• The same procedure repeated during a visit to theatre involving more than one entry point/approach and more than one non-bilateral siteAssign a code for each procedure



• Multiple procedures cont.−Classification guidelines cont.

• Skin or subcutaneous lesion removalAssign code for excision of multiple lesions by site


Excision of lesions from eyelid (1) and nose (1) and neck (2).

Codes: 31230-00 [1620] Excision of lesion(s) of skin and

subcutaneous tissue of eyelid

31230-01 [1620] Excision of lesion(s) of skin and subcutaneous tissue of nose

31235-01 [1620] Excision of lesion(s) of skin and subcutaneous tissue of neck


• Where there is no documentation of size, duration or number −follow the index default code

• If there is no default, assign a code for−the smallest size−the least duration−the least number of lesions−The least number of sites

ACS 0038 Procedures distinguished on the basis of size, time or number of

lesions or sites


• Refer to Block 1916 General allied health interventions

• For inpatient coding−assign a code from block [1916] to identify allied

health interventions−only one code per professional group

for each admission

ACS 0032 Allied health interventions



Line Coding

a) Wedge resection of the toenail for ingrown nail

b) Male admitted for drainage of pilonidal cyst

c) Transurethral prostatectomy for benign prostatic hypertrophy

87


Line Coding cont.

d) Unilateral, partial thyroidectomy for thyrotoxicosis

e) Excision of wart from tip of nose (skin)

f) Patient with mature senile cataract for intracapsular removal and insertion of intraocular lens

88


Anaesthesia


• Anaesthesia−partial or complete loss of

sensation−use of drugs to induce anaesthesia

• Assign an anaesthetic code for each ‘visit to theatre’

• If more than one anaesthetic given, code according to hierarchy in ACS

ACS 0031 Anaesthesia


• Cerebral anaesthesia – block [1910]−general anaesthesia (GA) – assign when artificial an

airway is used−sedation – assign when no artificial airway is used

• Conduction anaesthesia – block [1909]−neuraxial block – epidural, spinal, caudal −regional block – based on the general anatomical

area of the field of anaesthesia−infiltration of local anaesthesia – not coded

ACS 0031 Anaesthesia cont.


• Anaesthesia in labour−92507-xx [1333] Neuraxial block during labour and

delivery procedure

−Assigned for neuraxial block for pain relief in labour and then continued for anaesthesia during a delivery procedure.



• American Society of Anesthesiologists (ASA) score • Two character extension −1st character = the score that is documented by

the anaesthetist on the anaesthetic/operation form (1-9)

−2nd character = modifier of ‘E’ for emergency cases (0, 9)

• must be documented before assigning ‘0’ • if not documented assign ‘9’



• Guidelines for coding anaesthesia−only one code from either [1909] or [1910] is to be assigned for

each visit to theatre

− if more than one code in a block use hierarchy

−sequence the anaesthesia code following the procedure code(s) it relates to

−assign a code from [1912] Postprocedural analgesia when a neuraxial or regional block is continued after the procedure

−procedures not normally coded ARE coded if they are performed under anaesthesia



Ventilatory support


Ventilatory support• ACHI codes for CVS are found in block [569] and

NIV in block [570]– Block [569] Ventilatory support:

13882-00 ≤ 24 hours 13882-01 > 24 and < 96 hours13882-02 ≥ 96 hours

– Block [570] Noninvasive ventilatory support:92209-00 ≤ 24 hours 92209-01 > 24 and < 96 hours92209-02 ≥ 96 hours

96


Ventilatory support cont.

The classification of CVS and NIV is based on the number of hours i.e. ≤ 24 hours, > 24 and < 96 hours or ≥ 96 hours.

All cases of CVS and NIV should be coded.

The classification of CVS and NIV is based on the number of hours i.e. ≤ 24 hours, > 24 and < 96 hours or ≥ 96 hours.

All cases of CVS and NIV should be coded.

97


• ACS 1006 Ventilatory support– Definition

Noninvasive ventilation Continuous ventilatory support

(NIV) (CVS)



• ACS 1006 Ventilatory support cont.– Definition of CVS



• ACS 1006 Ventilatory support cont.– Definition noninvasive ventilation

– NIV includes:• Bi-level positive airway pressure BiPAP• Continuous positive airway pressure CPAP• Intermittent positive pressure breathing IPPB etc.



• ACS 1006 Ventilatory support cont.– Guidelines for coding ventilatory support:

• When both CVS and NIV are used for treatment, code each separately refer block [569] and [570]

• Subsequent periods of the same type of ventilation are added together

• Calculated as completed cumulative hours



• ACS 1006 Ventilatory support cont. - Cumulative hours (all hours ventilatory support are

added together), so only one code for duration is needed based on the type of ventilatory support

35 year old man admitted in acute respiratorydistress, intubated and ventilated in ICU for 46 hours

Look up:Management (for the duration)

ACHI codes:13882-01 [569] Management of continuous ventilatory support, > 24 and < 96 hours

ACHI codes:13882-01 [569] Management of continuous ventilatory support, > 24 and < 96 hours



• ACS 1006 Ventilatory support cont.– Guidelines for coding CVS cont.:

• Do not code methods of weaning (eg CPAP, IMV) separately. Weaning is included in calculating the length of time that a patient is on ventilatory support.

• Do not code ventilation when patient brings in their own ventilatory support devices

• Ventilation provided during surgery is associated with anaesthesia and if provided for ≤ 24 hrs, do not code



• ACS 1006 Ventilatory support cont.– Guidelines for coding CVS cont.

• Code a tracheostomy if it was performed with CVS from Block [536]

• Do not code any method of intubation (e.g. ETT) for ventilatory support

• Do not code any noninvasive airway (e.g. mask, nasal prong)



• ACS 1006 Ventilatory support cont.– Calculating the duration of CVS – for the purposes of

coding, CVS starts when:• the patient is intubated anywhere in your hospital, or

• CVS is started through the patient’s tracheostomy, or

• at the time of admission for those patients who have been admitted already intubated and ventilated



• ACS 1006 Ventilatory support cont.– For the purposes of coding, CVS ends when:

• the patient is extubated, or• the CVS is ceased after any period of weaning, or• CVS via the tracheostomy is stopped, or• the patient is discharged, transferred from your

hospital or the patient dies, or

• when a change of episode occurs



• ACS 1006 Ventilatory support cont.– Transferred patients:

• Intubated and ventilated» Assign a code for the appropriate hours of CVS at both the

transferring and receiving hospitals

• Intubated (without ventilation)» Transferring hospital assigns a code for the

intubation/tracheostomy if performed» Receiving hospital assigns a code for the management of the

intubation



Pharmacotherapy


Pharmacotherapy

• Terminology– PHARMACOTHERAPY

• defined as ‘the treatment of a condition by means of drugs’

109


Pharmacotherapy cont.• Terminology cont.

– ‘administration’ or ‘administration of agent’ is the preferred terminology not ‘injection/infusion/instillation’.

– Exception for blocks 32–37 (epidural/spinal/caudal) for coding of pain management

110


• [1920] Pharmacotherapy– Codes made up of

• 5 digit core = route of administration• 2 digit extension = drug type

• Use of codes– must follow coding conventions and only assign

drug administration codes from Block [1920] Pharmacotherapy when meets appropriate coding standards or conventions.

Pharmacotherapy cont.

111


• Multiple drugs given at same administration– Code the individual drugs administered

– Assign the extension that indicates the main intent of the pharmacotherapy

– If the main intent of the pharmacotherapy is unknown, assign code highest in the hierarchy (i.e. the lowest number)


112


• Multiple administration of the same drug– When a patient receives multiple administrations

of the same drug by the same route, within one episode of care, assign the pharmacotherapy code once only.


113


• Vascular access devices – An implanted venous catheter with a reservoir

attached

• Drug delivery devices– A device (e.g. ambulatory, external infusion pump)

attached to a vascular access device



• Vascular access device – Port-A-Cath



• Huber needle



• Block 766 Vascular access device

– Includes codes for:34528-02 [766] Insertion of vascular access device34530-06 [766] Revision of vascular access device34530-05 [766] Removal of vascular access device


117


• Loading of a drug delivery device can be found at Block 1920 for example:

• Maintenance codes at Block 1922


118


• Same-day admission for ‘management’ only of vascular access/drug delivery device assign as PDx:

orZ45.1 Adjustment and management of infusion pumpZ45.1 Adjustment and management of infusion pump

Z45.2 Adjustment and management of vascular access deviceZ45.2 Adjustment and management of vascular access device




Anaesthesia 1A 76 year old man was referred by his local doctor for treatment of a tension pneumothorax. He also suffers from COAD which further unbalanced the tension pneumothorax. A chest tube was inserted under a sedation (ASA 2) to drain the pneumothorax. A follow-up x-ray showed significant reduction in the size of the pneumothorax.

121


25 year old Darko presented with acute abdominal pain for the past 24 hours. He stated that he felt nauseous, had vomited twice and did not feel like eating. A physical examination confirmed a diagnosis of acute appendicitis and he was taken to theatre for an emergency appendicectomy (GA 2E). At laparotomy the appendix was seen to be ruptured and there was evidence of peritonitis. The appendix was removed and a peritoneal lavage was performed.

continued next slide......

122

Anaesthesia 2


continued...

The following day the patient was still unwell with fever, chills, shaking and tachycardia. His white cell count was elevated and blood was taken for culture. Microbiology results confirmed Staphylococcus aureus septicaemia. He was transferred to ICU and treated with IV antibiotics and fluids. He improved over the next few days and was transferred back to the ward for discharge at the end of the week.

123

Anaesthesia 2 cont.


This 48 yo male was admitted for renal transplant. He has chronic renal failure, end-stage. He has been maintained on haemodialysis for a number of years, however his condition deteriorated significantly and he was placed on the transplant waiting list. He underwent a renal transplant under combined GA and regional block (ASA 3). He was started on a triple immuno-suppression regimen. He was discharged and is for follow-up in the renal clinic in one week.

124

Anaesthesia 3


Patient is on ventilatory support for 2 hours prior to surgery, has the surgery for 5 hours and is ventilated for a further 12 hours after surgery.

125

Ventilation 1


Patient is ventilated for 12 hours prior to surgery, has the surgery (3 hours) and is ventilated for a further 6 hours after surgery. The following day the patient is again ventilated for 3 hours prior to surgery, has the surgery (10 hours) and is ventilated for another 12 hours. Two days later the patient goes into respiratory failure and is ventilated for 48 hours.

126

Ventilation 2


Patient is intubated and ventilated for surgery (2 hours) and extubated in recovery. Two days later the patient goes into respiratory failure and is ventilated for 24 hours.

127

Ventilation 3


Patient with chronic emphysema is placed on CPAP for 24 hours. This is reduced to 12 hours off during the day and 12 hours on at night for the next 3 days.

128

Ventilation 4


Patient goes into respiratory failure and is intubated and ventilated for 24 hours. They are weaned via CPAP for a further 2 hours and extubated successfully. The following day due to poor respiratory effort they are given CPAP for another 12 hours.

129

Ventilation 5


Ventilation 6

A female patient presented with a history of chronic maxillary sinusitis. She complained of experiencing continuous postnasal drip, recurrent rhinitis and often severe pain. A bilateral Caldwell-Luc operation was performed under GA (ASA 1). Postoperatively she suffered a respiratory arrest in recovery and was intubated and ventilated. She was transferred to the intensive care unit (ICU) and extubated after 34 hours.

130


Pharmacotherapy 1

Patient with Crohn’s disease admitted same day for treatment with IV infusion infliximab via a PICC line.

131


Same-day admission for removal of spinal infusion device under sedation (ASA 1).

132

Pharmacotherapy 2


Patient with carcinoma of the pancreas admitted for chemotherapy via infusion pump. Chemotherapy cassette changed and infusion pump set for 7 days at a dose of 200mg per 24hrs. Patient discharged home on same day.

133

Pharmacotherapy 3


Specialty coding and Coding support

Wednesday, November 20th, 2013


Cardiovascular


Cardiovascular

• Coronary artery bypass grafts (CABGs)– are performed to improve blood flow to the heart

muscle

• For correct code assignment, need to know:– the number of coronary arteries grafted– the type of material used


• Coronary artery bypass grafts (CABGs) cont.– also need to code cardiopulmonary bypass (CPB) if

performed e.g.

Cardiovascular cont.


• ACS 0909 Coronary artery bypass grafts

– Provides detailed medical science information– Classification guidelines– List of routine procedures performed with CABGs

that are NOT coded• e.g. cardioplegia, hypothermia, pacing wires

– Reoperation CABGs


138


• Pacemakers and defibrillators

– ACS 0936 Cardiac pacemakers and implanted defibrillators

– Terminology

• Pacemaker leads are now referred to as electrodes

– Assign codes for both pacemaker device and electrodes


139


• Pacemakers– Single and dual chamber – Biventricular/triple chamber– Implantable cardioverter defibrillators (ICDs)– Combined ICD and Pacemaker device


140


• ACHI codes

– One set of electrode codes for use with pacemakers and ICDs

– Combined pacemaker/defibrillator concept in the defibrillator code


141


• ACHI codes cont.– Blocks 650 and 653 are for insertion of cardiac

pacemaker/defibrillator generator– Insertion of electrodes can be found in Blocks

647–649– Codes in Blocks 654, 655 and 656 for ‘adjustment’

and ‘replacement’ pacemaker or defibrillator electrodes and cardiac pacemaker or defibrillator generator



• ACS 0936 Cardiac pacemakers and implanted defibrillators – Definitions

• Implantable cardiac defibrillator functions• For placement of an electrode into the atrium or ventricle• Single, dual and triple chamber pacemakers and

defibrillators


143


• ACS 0936 Cardiac pacemakers and implanted defibrillators cont.– Classification guidelines

• Assign code for insertion:– Pacemaker device 38353-00 [650] Insertion of cardiac

pacemaker generator– Defibrillator device 38393-00 [653] Insertion of cardiac

defibrillator generator• Code also insertion of electrodes:

– Pacemaker or defibrillator electrode(s) from Blocks 648 or 649


144


• ACS 0936 Cardiac pacemakers and implanted defibrillators cont. – Classification guidelines cont.

EXAMPLE 1:Transvenous insertion of a permanent defibrillator electrode into the right ventricle and a permanent pacemaker electrode into the right atrium.

Assign: 38390-02 [648] Insertion of permanent transvenous electrode into other heart chamber(s) for cardiac defibrillator

and38350-00 [648] Insertion of permanent transvenous electrode into

other heart chamber(s) for cardiac pacemaker

EXAMPLE 1:Transvenous insertion of a permanent defibrillator electrode into the right ventricle and a permanent pacemaker electrode into the right atrium.

Assign: 38390-02 [648] Insertion of permanent transvenous electrode into other heart chamber(s) for cardiac defibrillator

and38350-00 [648] Insertion of permanent transvenous electrode into

other heart chamber(s) for cardiac pacemaker


145


• ACS 0936 Cardiac pacemakers and implanted defibrillators cont.– Classification guidelines cont.

• ‘Testing’, ‘Reprogramming’, ‘Replacement’, ‘End-of-(battery) life’ and ‘Complications…’ include guidelines for pacemakers and defibrillators

• Guidelines for ‘Removal’ and ‘Adjustment’ of permanent pacemaker or defibrillator


146


Pacemakers and defibrillators – Points to remember

do not code routine testing of pacemaker at time of insertion

for replacement, assign a code for the replacement of the generator and/or any electrodes

elective admission (diagnosis code) for replacement of pacemaker/defibrillator (‘end of life’) is Z45.0 Adjustment and management of cardiac device with the appropriate procedure codes

Z95.0 Presence of cardiac device should be assigned for all other surgical cases not related to the management of the pacemaker




• Heart Valves– 4 valves

• Aortic• Mitral• Tricuspid• Pulmonary

• Heart Valve repair– Annuloplasty– Valvuloplasty

148


• Heart Valve replacement– Removal and replacement– Types of replacements:

• Bioprosthetic, Mechanical, Biological


149


• Anatomical section in ACHI for each valve– Blocks for repair and replacement

• Aortic valve – [622] & [623]• Mitral valve – [626] – [628]• Tricuspid valve – [632] – [634]• Pulmonary valve – [637]


150


Cardiac catheterisation and coronary angiography•Blocks for these procedures are:

– [667] Cardiac catheterisaton• Codes split on laterality

– [668] Coronary angiography• Codes split on with/out heart catheterisation and

laterality – [607] Examination procedures on left ventricle

• Codes split on laterality


151


• ACS 0933 Cardiac catheterisation and coronary angiography– Definition– Classification guidelines– Default codes when no documentation of which

side of heart:• Patients < 10 years old – left and right (assign 38206-00

[667] Right and left heart catheterisation)• Patients > 10 years old – left (assign 38203-00 [667]

Left heart catheterisation


152


• Blocks for angioplasty procedures– [670] Transluminal coronary angioplasty– [671] Transluminal coronary angioplasty

with stenting– Codes split on

• Open/closed procedure• Number of arteries• Number of stents


153


Obstetrics


Obstetrics

• DRG grouping defaults for:– O10 - O46, O98, O99 - antepartum– O60 - O75, O80–O82 - delivery– O15.2, O71, O72, O85–O92 - postpartum

• Z37.0 Single live birth – changes default to delivery

• Z39.0 Care and examination immediately after delivery – changes default to postpartum


Obstetrics cont.• Special chapter of ICD-10 take precedence over

system chapters

• Organised according to progress of a pregnancy – antenatal, delivery, postnatal

• Contains codes that describe all obstetric conditions in the mother (from conception to 42 days after delivery)


Obstetrics cont.• Other maternal disorders predominantly related

to pregnancy (O20–O29) – Contains categories and codes for common

conditions in pregnancy

– Block 020–029 is not very extensive and only contains specific codes for common complications

– No general codes in this block


• Other maternal disorders predominantly related to pregnancy (O20–O29) continued– O24 Diabetes mellitus in pregnancy and O25

Malnutrition in pregnancy are also used for the same condition if it arises in delivery and the puerperium

– There are different codes for:• pre-existing diabetes mellitus• gestational diabetes

Obstetrics cont.


Obstetrics cont.• Analgesia and anaesthesia during labour

and delivery– Patient may have

• Analgesic – to relieve pain• Anaesthetic – for partial or complete loss of sensation

– A Neuraxial block for pain relief (epidural) may be continued for anaesthesia (for caesarean, repair of obstetric tear etc).

– Codes in block [1333] used for the above see next slide for an

example…


Obstetrics cont.


• Analgesia and anaesthesia during labour and delivery cont.– If neuraxial block for caesarean only (no pain relief

prior) then code from block [1909] is assigned

Obstetrics cont.


Obstetrics cont.• ACS 1513 Induction

– Causing labour to start artificially• Surgical – artificial rupture of membranes (ARM)• Medical – infusion of drug (oxytocin)

– Need to code the procedure of induction and (if documented) a diagnosis code for the reason for the induction

– Codes are found in Block 1334 Medical or surgical induction of labour


Obstetrics cont.• ACS 1513 Induction cont.

– Augmentation is the increasing of uterine contractions after labour has begun spontaneously

– Different procedure codes for augmentation found in Block 1335 Medical or surgical augmentation of labour

– Do not mix induction and augmentation procedure codes

– Cannot assign codes from both Blocks 1334 and 1335 on the same episode


Obstetrics cont.• Outcome of delivery

– Every delivery episode for gestation > 20 weeks must have a code for outcome of delivery (Z37-)

• Indicates number of babies and whether liveborn or stillborn

– Z37.- indicates that the delivery took place during this admission


Perinatal• ACS 1615 Specific interventions for the sick

neonate – Interventions to be coded for neonates (not

normally coded for other patients)• Enteral infusion• Oxygen therapy• Parenteral fluid therapy• Parenteral antibiotics/anti-infectives• Phototherapy – code only if administered for > 12hrs


Perinatal cont.• ACS 1615 Specific interventions for the sick

neonate cont.– Respiratory support in the neonate

• Ventilation as a means of resuscitation at birth should not be coded

• Code as per the guidelines in ACS 1006 Ventilatory support with the following points:

- Continuous ventilatory support (CVS) should be coded in neonates regardless of the duration (except if initiated during surgery and not exceeding 24 hours)

- NIV should always be coded e.g. CPAP based on hours of duration


Skin Procedures

167


Debridement & Dressings• Debridement procedures, Index look up

– Debridement, burn– Debridement, skin

• Codes located in different blocks• Block 1627 Debridement of burn• Block 1628 Other debridement of skin and subcutaneous

tissue

168


Debridement & Dressings cont.• Dressings of burns are separate from other

dressings of other wounds, Index look up– Dressing, burn– Dressing, by type

• Codes located in different blocks• Block 16 Dressing of burn• Block 1601 Dressing of other wound

169


Debridement & Dressings cont.

• ACS 1203 Debridement– Excisional

• Burns• Skin & subcutaneous tissue

– Nonexcisional• Burns (<10% or > 10%)• Skin and subcutaneous tissue with or without bone or

cartilage involvement

– Default to excisional

170


Debridement & Dressings cont.• If multiple dressings and debridements

performed in same operative episode – code only once

• If both debridement and dressing performed in same operative episode of same site – code only debridement

• ACS 0042 Procedures normally not coded– Dressings only coded if performed under anaesthetic

171


VAC Dressings

• Vacuum assisted wound closure (VAC® dressing)

172


VAC Dressings cont.

• Wound dressing but is a nonexcisional debridement

• Correct code assignment – 90686-01 [1628] Nonexcisional debridement

of skin and subcutaneous tissue

OR– 90686-00 [1627] Nonexcisional debridement

of burn

173


Wound repairs

• ACS 1217 Repair of wound of skin and subcutaneous tissue– Definitions for:

• Superficial wound repair• Deep wound repair

– Do not code suturing of skin and subcutaneous tissue in the repair of soft tissue structures in deep tissue wounds

174


Wound repairs cont.

• Block 1635 Repair of wound of skin and subcutaneous tissue

• Codes based on:– Site – face or neck / other– Superficial / involving soft tissue– If specific structure of soft tissue is documented code

to repair of specified structure

175


Grafts and flaps• Grafts and flaps are the transplantation of healthy

tissue • Maybe used on different tissue not just skin• Grafts do not have own blood supply• Used to treat– Burns– Injuries– Areas of extensive skin loss– Defects

176


Skin grafts

• Terminology found in ACHI– Autograft uses skin from the patient’s

own body– Allograft uses skin from another human

being– Xenograft uses skin from a nonhuman

species– Synthetic and cultured skin

177


Skin grafts cont.

• More terms– Split thickness– Full thickness– Composite– Simple graft– Complicated graft– Small graft– Large graft

178


Skin grafts cont.• Skin graftsFollow the index:Graft (repair) - skin (autogenous) (free)

(mucous membrane) - - then site or graft type

Separate codes for skin grafts for burns

Graft (repair) - skin (autogenous) (free)

(mucous membrane) - - for burn- - - then site or graft type

179


Skin grafts cont.

• Blocks 1640 to 1650• Type of graft• Burn• Description of area• Site

180


Skin grafts cont.

– Codes• Type of graft• Size of graft• Site of graft• Burn site• % of area grafted

181


Flaps

• Has its own blood supply• Types– Single tissue flaps:

• Skin, fascia, muscle, bone, viscera

– Composite flaps:• Fasciocutaneous• Myocutaneous• Osteofasciocutaneous

182


Flaps cont.• Local flap – donor site next to recipient site

– Advancement – Rotation– Transposition– Interpolation

• Distant flap – donor site is different body site– Pedicel flap– Free flap

183


Flaps cont.

• Follow the index:Flap (repair) - then site or flap type

– No separate codes for burns

184


Flaps cont.

• Blocks 1651-1654– Type of skin flap– Size of flap– Complicity

• Blocks 1671-1674– Type of flap

185


Flaps cont.• Blocks notes

186


Flaps cont.

• Codes– Type of flap– Site of flap– Size of flap– Stage of procedure

• Examples

45206-00 Local skin flap of eyelid

45221-01 Direct distant skin

45227-00 Indirect distant skin flap, formation of tubed pedicle

45221-01 Direct distant skin

187



Cardiovascular 1

A patient was admitted with coronary artery disease in 3 arteries. He underwent surgery and the Theatre Sister entered the following procedures in the theatre log.

Which interventions would you code?continued next slide.....

189


190

Procedure Yes No

Insertion of endotracheal tube

Infusion of GA

Cardioplegia

Cardiopulmonary bypass

Sternotomy

Procurement of saphenous vein from (L) leg

Suture of saphenous vein to coronary artery

CABG x 3

Temporary pacing wires

Insertion of wire to sternum

Suture of thoracic wound

Cardiovascular 1 cont.


This male patient with a history of ongoing chest pain, was admitted to hospital for a left heart catheterisation and coronary angiogram. He also smokes a pack of cigarettes a day. A left cardiac catheterisation with coronary angiography was performed under local anaesthetic. The results showed severe coronary artery disease of 2 arteries. The Cardiothoracic surgeon decided that a double bypass was needed and the patient is to be readmitted in two weeks for surgery.

191

Cardiovascular 2


Cardiovascular 3

This patient with coronary artery disease (CAD) was admitted for surgery. PTCA (Percutaneous transluminal coronary angioplasty) was performed under sedation where a single stent was placed in one coronary artery (LAD).

192


Cardiovascular 4

Patient admitted with severe lower back pain. The Consultant performed a spiral arteriography under GA (ASA 1) which revealed occlusion of the vertebral artery. The Consultant then proceeded to a percutaneous transluminal balloon laser angioplasty with insertion of a single stent. Patient was discharged 2 days later.

193


Cardiovascular 5Admission: 21/4/xx Discharge: 24/4/xxSex: M Age: 63 M.O.: Dr GongoloDx: Sick sinus syndrome / bradycardia

Presenting condition:Patient with a history of sick sinus syndrome presents for insertion of a permanent pacemakerOther Conditions:HypertensionGoutPeripheral vascular disease


194


Cardiovascular 5 cont.continued...

Procedures:22/4/xxInsertion of VVI permanent pacemaker and ventricular pacing lead (right subclavian vein approach) under a general anaesthetic (ASA 2). Post op complication:Acute gout (L) ankle treated with medication.

Follow-up appointment:Patient was discharged home and will be followed up in 6/52 in rooms.

195


This patient with severe mitral valve incompetence underwent mitral valve replacement with a bioprosthesis under a GA (ASA 2) and with Cardiopulmonary bypass. Recovery went well and she was discharged home.

Cardiovascular 6

196


Cardiovascular 7

This fifty-eight year old female presented to the Emergency department after experiencing pressing and squeezing pain, under her breast bone following a brisk walk after her evening meal. A previous cardiac catheterisation had confirmed CAD. She was stabilised and taken to theatre where she was ventilated and placed on a cardiopulmonary bypass machine.


197


Cardiovascular 7 cont.continued...

Coronary artery bypass grafts using left internal mammary graft to LAD, saphenous vein graft to PDA, RDA and marginal circumflex artery was then performed under GA (ASA 3. She was successfully taken off bypass following surgery and returned to the ward and extubated after 12 hours. Her post operative recovery was excellent and she was discharged home to be followed-up in the Cardiac Clinic

198


Obstetrics 1

30 year old lady admitted for ‘trial of scar’ due to a previous LSCS. She was admitted in labour, membranes having ruptured at 8:00. Syntocinon was commenced and an epidural was inserted for pain relief. As the baby showed signs of heart decelerations, the epidural was topped up and a mid-forceps delivery of a healthy female infant was performed. Episiotomy was repaired.

199


Obstetrics 237/40 pregnant female was admitted to the maternity ward with increased blood sugar levels. She has been a Type 2 diabetic for the last 5 years. During her pregnancy she required insulin to maintain her sugar levels. She was assessed by both the obstetric and endocrinology teams with regards to the increasing risk of her diabetes to the baby. The decision was made to perform a lower segment caesarean section under epidural. A healthy live female infant was delivered by LSCS 2 days after admission.

200


Obstetrics 3Patient admitted at 40 weeks for induction of labour due to breech presentation. Induction of labour was via ARM and IV Syntocin. Epidural was given for pain relief during labour. Labour progressed to a successful assisted breech delivery of a live male infant. Third degree obstetric laceration was repaired using local anaesthetic.

201


Perinatal 1

Premature baby (1350grams), born at 31 completed weeks gestation, with an Apgar score of 3 at 1 minute, subsequently developed pneumothorax, respiratory distress syndrome and physiological jaundice of prematurity and was admitted to special care nursery (SCN). Interventions included IV antibiotics for 5 days, CPAP and oxygen therapy for 48 hours and phototherapy for 3 days.

202


Skin procedures 1 Patient admitted for excision of a squamous cell carcinoma of his left ear (pinna). Under general anaesthetic (ASA 2) the patient underwent an excision of the SCC with a full thickness skin graft. Donor site was the left side of the neck.

203


Skin procedures 2

Patient was admitted complaining of a 4 month problem relating to her left eyelid which wasn’t meeting when she closed her eyes. Physical examination was normal apart from her eye problem which was diagnosed as a left ectropion. She went to theatre where under GA (ASA 1) a wedge excision with repair of the ectropion of her left lower eyelid was performed with a split skin graft

204


Skin procedures 3A 2 year old boy was admitted following a burn injury to his right arm after he pulled a cup of hot tea off the kitchen table at home. He had second degree burns to his right forearm (BSA 4%) and some minor first degree burns to his hand (BSA 1%) . He was taken to theatre and under a GA the burns of his chest and forearm were debrided. Skin was excised from his right thigh and a split skin graft was applied to his right forearm. Dressings were applied to his hand.

205


Coding QueriesCoding advice

Auditing


Coding query mechanism

• Two-way process

– Avenue to resolve coding problems

– Provide feedback on problem areas

207


What is a coding query?

• Answer to problem areas in coding:– New condition – no code– New procedure – no code– Limited medical science knowledge– Incomplete understanding of classification

system– ‘Alone’ coder

208


Coding advice

• Crucial to the coding process• Helps maintain accurate and consistent

data• Reduces variations in decisions• Provides support to coders

209


Who provides the answers?• Sound knowledge of:

– Medical science– Medical terminology– Coding and classification system– Coding conventions– Coding standards/guidelines

210


Query process

• Written NOT verbal

– Allows for consistent responses– Storage of responses– No misunderstanding– No misinterpretations– Does not allow for dissemination

211


Query process cont.

• Set guidelines

• Document the process– Submission of query– Response to query

212


Steps in query process

1. Coder responsibility

– Review the classification– Reference texts, web– Seek advice locally– Send off for advice

213


Steps in query process cont.

2. Submission of the query– Email– Fax– Web submission

3.Query form– Detailed information

• Enquirer• Query

214


Example

215


Example - Electronic

216



4. Reviewing the query

– Review the classification– Check the query database– Check other classifications– Reference texts, websites– Seek clinician advice

217



4. Reviewing the query cont.

– Seek international advice– Circulate & discuss– Prepare a response– Publish the query– Submit feedback to the authors

218


Query database

• Storage

• Easy reference

219


Example

220


Publishing Q&As

• Up-dates coder workforce

• Consistent solutions to problems

• Coder education

221


Publishing Q&As

• Methods

– Coding magazines

– Websites

222


Example - Australia

The 10-AM Commandments223


Example - Australia

224


Example - Ireland

225


Development and use of internal audit programs


Assessing coding quality

• Auditing• Round table• Output editing• Focused study of LOS outliers

227


Quality activity plan• Scope of the program

• Objectives of the quality activities

• Methods by which these are achieved

• Individuals responsible for conducting activities

• Reporting structure

228


Quality activity plan cont.• Discussion of results and action

• Confidentiality statement

• Method and frequency of evaluating the effectiveness of the program

• Evidence of improvement and refinement of the program over time

229


Sample Selection• Period of audit• Audit sample

– Random sample • representative of morbidity database• only some records will have errors

– Target sample • defined by coding manager or auditor e.g. specialty,

edit /error DRGs• only some records will have errors

230


Sampling method - Random

• Generate a listing of MRNs of all patients separated during the audit period.

• Sample size– 5% recommended– Minimum of 46

231


Round table method• Group of coders code the same records and

discuss the codes assigned

• Aims to create coding consistency

• Allows discussion of different answers

232


Round table method cont.• Non-threatening, educational

• Majority answer will not always be correct

• Group may be coders from:– one hospital– across hospitals in an area– across hospitals with a particular specialty

233


Focused study of LOS outliers

• Excessive numbers of length of stay outliers may indicate the presence of errors in coded data

• Review high LOS outliers in non-CC DRGs

234


Output editing

• Transposition

• Sudden increase or decrease in no. of cases

• Missing codes

• Mismatched codes

• Consistently erroneous coding patterns

• Consistent disregard for coding rules

• Use of obsolete codes

Review reports for ‘face value’ accuracy

235


Quality activities schedule

• Audit Tool– twice a year (random)– as required (targeted)

• ‘Face value’ identification– monthly

• Round table– quarterly or monthly

• Focused study of LOS outliers– monthly

236


Any questions?

Documents

DRG Workshop Belgrade, 18-22.November 2013. DRG Workshop 18 – 22 November 2013 Belgrade