Moncrief Army Community Hospital

Ft. Jackson, SC

A&T provides coder/auditors for on-site inpatient and outpatient coding, training and auditing services. A&T coders review and analyze medical documentation adequacy and instruct professional staff on documentation requirements as needed. Audits are structured in accordance with government-provided instructions outlined in the current MHS Coding Guidelines and DoD coding audit methodology. Comparison analysis of RVU and RWP values for provider – coder – auditor review assists the coding team in focusing on potentially high risk areas.

MEDICAL CODING AUDIT

During the auditing process, coders are responsible for verifying and coding of the diagnosis, evaluation and management, procedures or any other codes required for the complete and accurate preparation of the SADR/SIDR and to support the Uniform Business Office to ensure the have the documentation to submit a clean claim. A&T Coder/Auditors are responsible for reviewing the medical record for the correct assignment of appropriate codes for all diagnoses for inpatient and outpatient treatment and appropriate codes for all procedures and inpatient professional visits performed while the patient is hospitalized or seen on an outpatient basis. Additionally, coders conduct audits for clinics, providers and data quality purposes. Audits are performed on a rotational basis. Each month 3-4 clinics are target until all clinics have been audited, then rotation begins again. The first audit rotation results in a baseline analysis in regards to provider and coder accuracy and clinical processes which affect coding. The second, tertiary, etc audits target the same areas in addition to problem areas noted during the baseline audit to monitor progress and develop training unique to needs. Training occurs throughout the entire process. First training session establishes DoD, MTF specific and industry standard coding and documentation rules and regulations specific to the specialty. Following training sessions review basics and target problem areas noted by the auditor and/or auditing team.

PROVIDER AUDIT
A&T supports providers in various way such as one-on-one training to providers needing more attention. Systems utilized are the CHCS, AHLTA and CCE. Resources include current coding manuals (ICD9, CPT, HCPCS), Ingenix Encoderpro coding software (CCI edits AMA and AHA references, etc). Ongoing provider education is conducted with A&T’s “Documentation and Analysis Feedback Forms.” The auditor briefly denotes issues encountered and attaches a copy of the AHLTA note for quick reference. If the record is incomplete which prohibits processing, a request is made to the provider to address and provide immediate feedback for processing. Providers also receive feedback for “A job well done.” This provides adequate education and keeps the communication lines open. A&T has been innovative in creating laminated coding tools as a quick E&M reference guide, developing pick lists and/or cheat sheets to assist the providers. A&T coders are mindful for tasks at hand, however the primary objective is to assist the providers. When monitoring is performed consistently, end results yield higher RVUs and RWPs. A&T coders are responsible for developing and assisting the providers and clinics in AHLTA template design. The combined efforts of the coder and AHLTA representative (AHLTA rep contract is ongoing) to create template to ease the provider’s process of choosing amongst thousands of documentation options, allows the provider more time with the patient and less time working with the system. A&T’s lead coder participates in the Data Quality audits and monthly meetings. Coding quota are required and calculated based on coded hours. Coders meet incentive criteria monthly by achieving the production goals established.

PROCESS AUDIT
A&T initiated a special project conducted by A&T’s Audit Manager to capture and demonstrate RVU collection needs for the hospital. ADM adhoc were generated to establish a baseline analysis of the provider’s evaluation and management levels. The report revealed that coded E/M levels were very low for the type of service a general surgeon would typically provide. A further analysis revealed that the provider had minimal AHLTA training and did not realize that he could change the E/M level after free texting. Other issues detected were lack of documentation in key elements (History, Exam and MDM), procedures and supplies not coded, missing modifier, etc. RVU accountability increased drastically by 108% after issues were found and addressed. A&T has worked closely with AHLTA and CCE trainers to correct systemic problems and are instructional in assisting the MTF in resolving CCE issues (ie grouping patient categories for the daily patient run list, etc).