1. LESSONS LEARNED FOLLOWING THE PATHWAYS CLAIMS VALIDATION
Acino R, Mason J, Russell T, Lurie F, Oriowo B
PROBLEM STATEMENT
The 2017 Claims Validation audit identified 12.2% of VQI cases submitted for payment had a coding miss-match impacting the Diagnosis Related Group (DRG). Examples include cases entered in VQI as open Carotid Endarterectomy (CEA) were billed as percutaneous, internal carotid arteries were not included in CEA codes, vessels for bypass cases were inaccurate and standard endograft procedures were coded incorrectly as fenestrated grafts.
GOAL
Use the results of the 2017 audit to investigate the accuracy of coding and to develop an action plan and quality improvement project (QI) to reduce billing and coding errors.
IMPROVEMENT STRATEGIES
Vascular surgery staff provided an education session to over 40 HIM staff reviewing vascular anatomy and common procedures. Coding staff was assigned American Health Information Management Association (AHIMA) webinars pertaining to AAA, bypass, and femoral percutaneous transluminal coronary angioplasty (PTCA) and stent coding education. Documentation tips for dictation and templates are being developed and implemented into the EMR to capture procedure variables to assist with correct coding and billing. 100% SMART review of Carotid Endarterectomy and AAA procedures is being conducted for all 2019 cases.
RESULTS
Charge codes pertaining to 2017 cases were updated and rebilled resulting in $17,661 rebilled at a loss, $12,131 rebilled at a gain, and $29,152 too old to rebill. Discussions between Vascular and HIM identified opportunities to improve education amongst the Health Information Coding (HIM) coding staff and improve documentation by providers.
CHALLENGES/LESSONS LEARNED
The accuracy of VQI data was confirmed, and the miss-match of coding was due to the coding errors. HIM staff identified difficulty with vascular coding due to the complexity of anatomy, procedures and devices. With the recent transition to EPIC EMR, templates and smart tools were low priority for IT due to the backlog of requests and other priority projects.
SUCCESS FACTORS:
Although the audit identified a relatively small financial impact, the importance of doing things correct resulted in a unique collaboration between HIM and vascular teams. The focus on education and development of tools to reduce errors and maximize reimbursement will result in a much greater impact in the future.