Software Solutions for Managing Coding (Billing) Compliance - - PowerPoint PPT Presentation

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Software Solutions for Managing Coding (Billing) Compliance - - PowerPoint PPT Presentation

Mar 06, 2024 162 likes •760 views

Software Solutions for Managing Coding (Billing) Compliance Minnette Terlep Senior Vice President United Audit Systems, Inc. 360 Gest Street Cincinnati, OH 45203 513-723-1122, extension 114 Software Solutions for Managing

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SLIDE 1

Software Solutions for Managing Coding (Billing) Compliance

  • Minnette Terlep
  • Senior Vice President
  • United Audit Systems, Inc.
  • 360 Gest Street
  • Cincinnati, OH 45203
  • 513-723-1122, extension 114
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SLIDE 2

Software Solutions for Managing Coding (Billing) Compliance

  • What is Coding (Billing)

Compliance?

  • Health Insurance Portability and

Accountability Act of 1996 Public Law 104-191 (HIPAA)

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SLIDE 3

Software Solutions for Managing Coding (Billing) Compliance

  • How are hospitals reimbursed

for Medicare inpatient services?

  • Diagnosis Related Groups (DRGs)
  • ICD-9-CM Coding Classification
  • Casemix
  • Blended rate
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SLIDE 4

Software Solutions for Managing Coding (Billing) Compliance

  • What is Coding Optimization?
  • DRG 321 Kidney/Urinary Tract Infection

W/O CC

  • DRG 416 Septicemia
  • DRG 321 rel. wt. .5785 $2,892
  • DRG 416 rel. wt. 1.4988 $7,494
  • Increase in Payment

$4,602

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SLIDE 5

Software Solutions for Managing Coding (Billing) Compliance

  • Is there proof that unethical

coding has occurred?

  • 1997 Office of Examinations and

Inspection Report (OEI-01-97-00010)

  • 5.2% upcoding in 20 hospital control group

compared to

  • 11.4% upcoding in 50 hospitals with high

predicted rate of upcoding

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SLIDE 6

Software Solutions for Managing Coding (Billing) Compliance

  • Have any hospitals been charged

with fraudulent coding and have those charges resulted in monetary settlements?

  • Louis Weiss Hospital - Chicago, IL
  • Sharp Healthcare - San Diego, CA
  • Edgewater Hospital - Chicago, IL
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SLIDE 7

Software Solutions for Managing Coding (Billing) Compliance

  • What are the HIPAA

requirements for monitoring coding (billing) accuracy?

  • Corporate Compliance Program
  • HIM Department Compliance Plan
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SLIDE 8

Software Solutions for Managing Coding (Billing) Compliance

  • What should be included in

the HIM Department Compliance Plan?

  • on-going prebilling monitors of

coding (billing accuracy)

  • documentation of review results
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SLIDE 9

Software Solutions for Managing Coding (Billing) Compliance

  • What should be included in

the HIM Department Compliance Plan?

  • ongoing inservice education to

prevent future errors

  • reporting of monitor findings

upwards through the organization

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SLIDE 10

Software Solutions for Managing Coding (Billing) Compliance

  • How does the current manual

process for selecting coding review cases compare to a computerized process?

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SLIDE 11

Software Solutions for Managing Coding (Billing) Compliance

Comparison of Chart Selection Manual Computerized

  • random
  • focused
  • statistically valid

random sample

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SLIDE 12

Software Solutions for Managing Coding (Billing) Compliance

  • Chart Selection
  • Focused
  • DRG
  • Physician
  • Coder
  • High-risk Coding Indicator DRGs
  • Algorithms
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SLIDE 13

Software Solutions for Managing Coding (Billing) Compliance

  • Chart Selection
  • Algorithms
  • DRG
  • Diagnoses/Procedures
  • Length of Stay
  • Discharge Disposition
  • Admission Source
  • Total Charges
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SLIDE 14

Software Solutions for Managing Coding (Billing) Compliance

  • Statistically Valid Random

Sampling

  • RAT-STATS Methodology
  • Other statistically valid sampling

techniques

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SLIDE 15

Software Solutions for Managing Coding (Billing) Compliance

  • Uses of Statistically Valid

Random Sampling

  • Statistically valid chart audit versus
  • ngoing prebilling coding quality

monitoring

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SLIDE 16

Software Solutions for Managing Coding (Billing) Compliance

  • How does the current manual

process for performing chart review compare to a computerized process?

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SLIDE 17

Software Solutions for Managing Coding (Billing) Compliance

Comparison of Review Process Manual Computerized

  • re-code records
  • re-code using

software clinical

reference tools to support potential code changes

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SLIDE 18

Software Solutions for Managing Coding (Billing) Compliance

  • Computerized Review Process
  • Clinical Reference Tools
  • Diagnoses/Procedures descriptions
  • Official Coding Guidelines
  • Coding Clinic Publication - AHA
  • High-risk Coding Indicator DRGs
  • Expert review recommendations
  • Coding policies and procedures
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SLIDE 19

Software Solutions for Managing Coding (Billing) Compliance

  • How does the current manual

process for documenting coding review findings compare to a computerized process?

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SLIDE 20

Software Solutions for Managing Coding (Billing) Compliance

Comparison of Review Documentation Process Manual Computerized

  • enter code changes
  • enter code changes
  • n paper worksheet

into log entry screen

  • hand-write reasons
  • select causes for

for code changes code changes from menu

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SLIDE 21

Software Solutions for Managing Coding (Billing) Compliance

Comparison of Review Documentation Process Manual Computerized

  • enter DRG change
  • enter DRG change
  • calculate payment
  • system calculates

change payment change

  • document other
  • select other data
  • information free form

to be entered from menu selections

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SLIDE 22

Software Solutions for Managing Coding (Billing) Compliance

  • How does the current manual

process for calculating accuracy rates compare to a computerized process?

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SLIDE 23

Software Solutions for Managing Coding (Billing) Compliance

Comparison of Calculating Accuracy Rates Manual Computerized

  • count total cases
  • select criteria* from

menu for calculating accuracy rates

  • count # DRG errors
  • count # codes assigned
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SLIDE 24

Software Solutions for Managing Coding (Billing) Compliance

What is included in report criteria*?

  • Date Range
  • Coder(s)/Department
  • Physician
  • Payor(s)
  • Reviewer(s)
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SLIDE 25

Software Solutions for Managing Coding (Billing) Compliance

Comparison of Calculating Accuracy Rates, con’t. Manual Computerized

  • count total cases

by coder

  • count # DRG errors

by coder

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SLIDE 26

Software Solutions for Managing Coding (Billing) Compliance

Comparison of Calculating Accuracy Rates, con’t. Manual Computerized

  • count total codes

assigned by coder

  • count total coding

errors

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SLIDE 27

Software Solutions for Managing Coding (Billing) Compliance

Comparison of Calculating Accuracy Rates, con’t Manual Computerized

  • enter counts into

spreadsheet software

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SLIDE 28

Software Solutions for Managing Coding (Billing) Compliance

Comparison of Calculating Accuracy Rates, con’t. Manual Computerized

  • perform calculations of

accuracy rates on spread- sheet

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SLIDE 29

Software Solutions for Managing Coding (Billing) Compliance

Comparison of Calculating Accuracy Rates, con’t. Manual Computerized

  • create graphs/reports
  • print graphs and
  • print graphs and

reports reports

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SLIDE 30

Software Solutions for Managing Coding (Billing) Compliance

  • How does the current manual

process for trending underlying cause of coding error compare to a computerized process?

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SLIDE 31

Software Solutions for Managing Coding (Billing) Compliance

Trending Underlying Cause of Coding Error Manual Computerized

  • analyze free
  • select criteria* for

form text from reporting worksheets underlying causes

  • f coding error
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SLIDE 32

Software Solutions for Managing Coding (Billing) Compliance

What is included in report criteria*?

  • Date Range
  • Coder(s)/Department
  • Physician
  • Payor(s)
  • Reviewer(s)
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SLIDE 33

Software Solutions for Managing Coding (Billing) Compliance

Comparison of Calculating Accuracy Rates, con’t. Manual Computerized

  • count total cases

by coder

  • count # underlying causes
  • f coding error by coder
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SLIDE 34

Software Solutions for Managing Coding (Billing) Compliance

Comparison of Calculating Accuracy Rates, con’t Manual Computerized

  • enter counts into

spreadsheet software

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SLIDE 35

Software Solutions for Managing Coding (Billing) Compliance

Comparison of Calculating Accuracy Rates, con’t. Manual Computerized

  • perform calculations of

underlying cause rates on spreadsheet

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SLIDE 36

Software Solutions for Managing Coding (Billing) Compliance

Comparison of Calculating Accuracy Rates, con’t. Manual Computerized

  • create graphs/reports
  • print graphs and
  • print graphs and

reports reports

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SLIDE 37

Software Solutions for Managing Coding (Billing) Compliance

  • How can national coding

indicator benchmarks be used to evaluate hospital coding accuracy?

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SLIDE 38

Software Solutions for Managing Coding (Billing) Compliance

  • MedPar Billing Data
  • Regional Billing Data
  • Inclusion of national/regional norms
  • High-risk indicators
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SLIDE 39

Software Solutions for Managing Coding (Billing) Compliance

  • Examples of Coding

Indicators:

  • CC DRG%

n “CC” DRGs X 100 = CC DRG%

n “CC” & n “no CC”DRGs

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SLIDE 40

Software Solutions for Managing Coding (Billing) Compliance

CC DRG%: FY ‘97 HCFA National Norm 81.8% FY ‘98 HCFA National Norm 80.3% Decrease 1.5%

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SLIDE 41

Software Solutions for Managing Coding (Billing) Compliance

  • Examples of Coding

Indicators:

  • Gram-negative to Simple Pneumonia

n DRGs 79/80/81 X 100 = ratio of sum (n DRGs 79/80/81 gram-negative + n DRGs 89/90/91) to all pneumonia DRGs

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SLIDE 42

Software Solutions for Managing Coding (Billing) Compliance

Gram-negative to All Pneumonia FY ‘97 HCFA National Norm 33.5% FY ‘98 HCFA National Norm 27.6% Decrease 5.9%

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SLIDE 43

Software Solutions for Managing Coding (Billing) Compliance

  • Examples of Coding

Indicators:

  • Septicemia to Urinary Tract Infection

n DRGs 416/417 X 100 = ratio of sum (n DRGs 416/417 septicemia + + n DRGs 320/321/322) to septicemia and urinary tract infection DRGs

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SLIDE 44

Software Solutions for Managing Coding (Billing) Compliance

Septicemia to Urinary Tract Infection: FY ‘97 HCFA National Norm 53.4% FY ‘98 HCFA National Norm 50.5% Decrease 2.9%

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SLIDE 45

Software Solutions for Managing Coding (Billing) Compliance

  • How does the current manual

process for using national benchmark indicators compare to a computerized process?

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SLIDE 46

Software Solutions for Managing Coding (Billing) Compliance

Comparison of Using National Coding Indicator Benchmarks Manual Computerized

  • sum total cases for
  • select criteria to

each DRG in each print report indicator

  • enter data into

spreadsheet software

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SLIDE 47

Software Solutions for Managing Coding (Billing) Compliance

Comparison of Using National Coding Indicator Benchmarks Manual Computerized

  • perform calculations of

benchmarks on spread- sheet

  • repeat same process using

National/Regional data

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SLIDE 48

Software Solutions for Managing Coding (Billing) Compliance

Comparison of Using National Coding Indicator Benchmarks Manual Computerized

  • create graphs/reports
  • print graphs and
  • print graphs and

reports reports

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SLIDE 49

Software Solutions for Managing Coding (Billing) Compliance

Criteria to Select Coding Compliance Software:

  • Software options
  • Old “optimization” software
  • Coding compliance software that

identifies both over and undercoding

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SLIDE 50

Software Solutions for Managing Coding (Billing) Compliance

Criteria to Select Coding Compliance Software:

  • Supports hospital’s corporate

compliance program requirements

  • Focuses on CORRECT coding -
  • vercoding, undercoding, coding

quality

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SLIDE 51

Software Solutions for Managing Coding (Billing) Compliance

Criteria to Select Coding Compliance Software:

  • Features clinical references
  • Includes Official Coding

Guidelines

  • Provides automated audit trail
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SLIDE 52

Software Solutions for Managing Coding (Billing) Compliance

Criteria to Select Coding Compliance Software:

  • Calculates financial impact of

coding changes

  • Includes national benchmarks
  • Provides graphs and reports
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SLIDE 53

Software Solutions for Managing Coding (Billing) Compliance

Criteria to Select Coding Compliance Software:

  • Supports multiple payors’ DRG

schemes

  • Profiles coders and physicians
  • Provides daily hotline support
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SLIDE 54

Software Solutions for Managing Coding (Billing) Compliance

Criteria to Select Coding Compliance Software:

  • Includes complimentary coding

advice hotline

  • Includes annual regulatory

updates in license fee

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SLIDE 55

Software Solutions for Managing Coding (Billing) Compliance

Summary

  • Hospitals must respond to HIPAA

regulations to monitor coding (billing) accuracy

  • Software solutions enhance

hospital’s ability to manage coding

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SLIDE 56

Software Solutions for Managing Coding (Billing) Compliance

Summary

  • This is accomplished by:
  • better chart selections
  • expert advice in conducting

review

  • efficiency in logging and

reporting review results

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SLIDE 57

Software Solutions for Managing Coding (Billing) Compliance

Summary

  • This is accomplished by:
  • being better informed through

national coding indicator benchmarks

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SLIDE 58

Software Solutions for Managing Coding (Billing) Compliance

United Audit Systems, Inc. - UASI