The quality of accurate coding is critical in today’s health climate. Coding is utilized for appropriate patient treatment, reimbursement, research, the basis of financial and clinical decision making and worldwide comparative trending. As a result, the accuracy of reported codes must be audited and analyzed to ensure the data is relevant and clinically validated. Show Coding has many nuances: coding guidelines that must be adhered to, internal code capture for statistical purposes and incentive programs are just a few factors to consider in the coding arena. With so many factors at play, accuracy should be established on two levels. An audit with a random sampling of 2% of the required productivity standard per patient type by coder should be chosen. Those records should be reviewed for Diagnostic Related Group (DRG) accuracy and overall coding accuracy. DRG accuracy of 95% and overall coding accuracy of 90% are both essential. Overall coding accuracy takes into account elements more than the diagnosis and procedure codes. Both accuracy levels should be evaluated so appropriate feedback can be made to the coder. Refining the skills of the coder is the ultimate goal so the facility has clean data that will be above question and audit-proof. DRG accuracy is one way of determining whether an in-patient record is accurately and completely coded. Any addition/deletion or revision of a code that changes the DRG is considered a DRG error. The audit score will be determined as such: DRG Accuracy = Total Number of Records Reviewed – Total Number of Records With a DRG Error / Total Number of Records Reviewed The overall coding accuracy should also be assessed for in-patient charts. This takes into consideration elements beyond code assignment such as present on admission indicators, discharge disposition, attending physician, operative date, operative physician and codes not affecting the DRG. It is calculated with a weighted scoring system. Overall In-Patient Coding Accuracy: The overall coding accuracy is determined by the percentage accuracy achieved for the individual record coded. Percentage of the overall accuracy is determined by assigning a percentage reduction for each of the following coding errors:
Individual Record Accuracy = 100% – Total Error Percentage Reduction The audit accuracy is the average of the individual record accuracies. The out-patient coding arena is just as important. Overall outpatient coding accuracy takes into account all diagnosis and procedure codes plus appropriate modifiers. Outpatient Coding Accuracy = Number of Correct Codes/Total Number of Codes In summary, coding accuracy is an important part of the revenue cycle of health care facilities. Auditing can reveal areas that need a corrective action plan. Educating coders, physicians and clinicians will help strengthen the documentation needed to support code assignments. Monitoring the effectiveness of this education through follow-up reviews is essential to continued success. For more information, visit www.ovationrcs.com. Review of the Health RecordAs described in Chapter 2 of this textbook, the first step in coding the principal diagnosis (condition established after study to be chiefly responsible for occasioning admission of the patient to the hospital for care), other reportable diagnoses, and procedures is review of the health record. The discharge summary (DS), if available, may be the first document to be reviewed for code selection. The coder reads the summary to understand the highlights of this encounter. The discharge summary is a synopsis of the events included in a patient’s hospital stay. Most pertinent information is contained in the discharge summary. A physician should list the diagnoses and the procedures that were performed during this encounter. The coder should not solely rely on the discharge summary to capture all diagnoses and procedures that occurred during this encounter. For many reasons, the discharge summary is not the only document from which codes are captured. Most coders start the coding process as they begin their document review. A coder is continually trying to determine the principal diagnosis during the record review. Clues to determination of the principal diagnosis can be found in the ER record or in the admitting orders. Physicians, in their admitting orders, give a reason for admitting the patient. When evaluating an ER record, a coder first looks for the chief complaint (CC), which is the reason in the patient’s own words for presenting to the hospital. Example CC: I have a bad cough, fever, and headache, and my throat is so sore I can’t even swallow liquids. As the coder continues the review of the ER document, the ER physician provides a diagnosis for admission to the hospital. The admitting diagnosis is the condition that requires the patient to be hospitalized. This condition may be a sign or a symptom that requires testing and evaluation to determine a diagnosis. This may be a known diagnosis or a probable diagnosis, or it may include a differential diagnosis. In the previous example, the ER physician might document, “Admit patient to the hospital for possible pneumonia and dehydration.” In this case, the pneumonia has not yet been confirmed, but the dehydration is known. A differential diagnosis occurs when a patient presents with a symptom that could represent a variety of diagnoses. During the patient’s stay a variety of studies may be conducted to rule out or confirm the differential diagnoses. Example A patient presents with abdominal pain, and the physician suspects that this might represent appendicitis, gastroenteritis, or cholecystitis. Appendicitis, gastroenteritis, and cholecystitis are differential diagnoses. A coder continues on through the health record, reviewing all progress notes, operative reports, anesthesiology notes, and consults to arrive at all diagnoses and procedures that need to be captured or reported. The second most important concept that a coder must remember (after the definition of principal diagnosis and principal procedure) is that once a term has been located in the Alphabetic Index, the code must then be verified in the Tabular Index. This is not the case in ICD-10-PCS, in which you do not need to refer to the Index before referring to the tables. What are the 7 steps to accurate coding?The process is easier when you break it into seven steps:. Review the header of the report.. Review the CPT® codebook (start in the Index).. Review the report/documentation.. Make a preliminary code selection.. Review the guidelines (for the preliminary codes).. Review policies and eliminate the extras.. What are the steps to accurate coding?Identify the main term(s) in the diaagnostic statement.. Locate the main term(s) in the Alphabetic Index.. Review any sub terms under the main term in the Index.. Follow any cross-reference instructions, such as "see.". Verify the code(s) selected from the Index in the Tabular List.. What are the 5 main steps for diagnostic coding?A Five-Step Process. Step 1: Search the Alphabetical Index for a diagnostic term. ... . Step 2: Check the Tabular List. ... . Step 3: Read the code's instructions. ... . Step 4: If it is an injury or trauma, add a seventh character. ... . Step 5: If glaucoma, you may need to add a seventh character.. What are the three main steps to coding accurately?Here are three steps to ensure you select the proper ICD-10 codes:. Step 1: Find the condition in the alphabetic index. Begin the process by looking for the main term in the alphabetic index. ... . Step 2: Verify the code and identify the highest specificity. ... . Step 3: Review the chapter-specific coding guidelines.. |
