TEAM HIT Performance Improvement Team Presentation Team Members

Mission Statement Vision Statement Evaluate the Health Information Management department’s coding process, identify areas to improve, and develop a coding compliance plan to ensure complete and accurate coding of health records and to ensure the best service for our customers through accuracy and integrity. Vision Statement The Health Information Management Department provides complete and accurate coding of all health records.

Customers and Requirements HIM Department Accurate codes applied to health records in a timely manner

Quality Assessment and Quality Assessment Tools Reviewed coding completed versus the audit results of 30 health records. Quality Assessment Tools: Unstructured brainstorming Regular meetings with an agenda Wiki Blog Email Graphs and Charts

Criteria Used

Audit Results

ICD-9-CM Results

CPT-4 Results

Recommendations Establish a Coding Compliance Plan which includes: Coding Conventions for Code Selection. Physician Query Process. Essential Coding Resources. Coding Quality and Integrity. Reporting Compliance Concerns. Training and Education.

Coding Conventions for Code Selection Using most current edition of ICD-9-CM, CPT-4, and HCPCS. Creating internal guidelines where no official guideline exists. Adhering to the National Correct Coding Initiative.

The Physician Query Process Query physician for ambiguous or incomplete documentation. Physician addendum attached to health record or face sheet. Query form is communication tool, not part of the health record. Query process is for clarification only. Goal of clarifying documentation is to reflect highest degree of specificity. Query process can be done concurrent or retrospectively.

Essential Coding Resources Current ICD-9-CM, CPT-4, and HCPCS Level II coding books. Official coding guidelines. Encoder and grouper system. Medicare Manuals. Fiscal Intermediary newsletters and bulletins. Local Medical Review Policies. Unique payer requirement policies and procedures. Current medical dictionaries and anatomy references. Current drug references. Internet access for coding, billing, and clinical research.

Coding Quality and Integrity No upcoding for higher payment. No unbundling for higher payment. Do not code based solely on test results. Do not add diagnosis/procedure codes to misrepresent patient’s clinical picture. Do not deviate from coding guidelines unless unique payer requirements are received in writing. Use established query process.

Reporting Compliance Concerns Report any concerns with practices or policies to immediate supervisor. Report may also be made to HIM manager or compliance officer. No retribution to employee for reporting what they believe to be an act of wrongdoing. Possible violations reported through a suggestion box, compliance hotline for anonymous reports, written or verbal reports to compliance officer.

Training and Education All employees will be required to attend specific training for new orientation and periodically during course of employment. Training will include federal and state statues, regulation program requirements, policies of private payers, and compliance policies of the facility. Training will be accomplished through several resources and a variety of means.