Audit and Compliance

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Audit and Compliance
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Audit and Compliance Whats it all about ..

• Audit is defined as an official examination and
  verification of accounts and records, especially
  of financial accounts.
• Compliance is defined as a state in which
  someone or something is in accordance with
  established guidelines, specifications, or
  legislation
• So what does this mean for HIM professionals
• We need to perform our duties while adhering to
  established guidelines and specifications as laid
  our by our governing bodies ..
• State Federal.. And Association

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Compliance

• Following established Federal Guidelines UHDDS
• Uniform Hospital Discharge Data Set
• The UHDDS definitions are used by acute care
  short-term hospitals to report inpatient data
  elements in a standardized manner. These data
  elements and their definitions can be found in
  the July 31, 1985, Federal Register (Vol. 50, No,
  147), pp. 31038-40.
• There are a total of 42 possible elements of a
  UHDDS form. First are basic demographic elements,
  such as age, gender, ethnicity, marital status
  and education levels. Another set has to do with
  the hospital or health facility, including
  patient numbering systems, type of facility and
  assigned doctor or nurse. Finally, complete
  information about the reason for the patient
  coming to the hospital is recorded, including
  self-reported diagnosis, physician diagnosis,
  services rendered by the facility and dates of
  all procedures.

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UHDDS Definitions

• Inpatient diagnoses and procedures shall be coded
  in accordance with Uniform Hospital Discharge
  Data Set (UHDDS) definitions for principal and
  additional diagnoses and procedures as specified
  in the Official Guidelines for Coding and
  Reporting.
• The principal diagnosis is defined in the UHDDS
  as, that condition established after study to be
  chiefly responsible for occasioning the admission
  of the patient to the hospital for care.

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Selection of Principal Diagnosis

• CODES FOR SYMPTOMS,SIGNS, AND ILL-DEFINED
  CONDITIONS
• Codes for symptoms,signs and ill-defined
  conditions from Chapter 16 are not to be used as
  a principal diagnosis when a related definitive
  diagnosis has been established.
• TWO -OR- MORE INTERRELATED CONDITIONS, EACH
  POTENTIALLY MEETING THE DEFINITION FOR PRINCIPAL
  DIAGNOSIS
• When there are two or more interrelated
  conditions (such as a disease in the same
  ICD-9chapter manifestations characteristically
  associated with a certain disease) potentially
  meeting the definition of principal diagnosis,
  either condition may be sequenced first, unless
  the circumstances of the admission, the therapy
  provided, the Tabular List, or the Alphabetic
  Index indicate otherwise.

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Selection of Principal Diagnosis

• TWO OR MORE DIAGNOSIS THAT EQUALLY MEET THE
  DEFINITION FOR PRINCIPAL DIAGNOSIS.
• In the unusual instance when two or more
  diagnoses equally meet the criteria for principal
  diagnosis as determined by the circumstances of
  admission, diagnostic workup and/or therapy
  provided, and the Alphabetic Index, Tabular List,
  or another coding guideline does not provide
  sequencing direction, any one of the diagnoses
  may be sequenced first.

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Selection of Principal Diagnosis

• COMPARATIVE -OR- CONTRASTING CONDITIONS.
• In those rare instances when two or more
  contrasting or comparative diagnoses are
  documented as "either/or" (or similar
  terminology), they are coded as if the diagnoses
  were confirmed and the diagnoses are sequenced
  according to the circumstances of the admission.
  If no further determination can be made as to
  which diagnosis should be principal, either
  diagnosis may be sequenced first.
• SYMPTOMS(s) FOLLOWED BY CONTRASTING/COMPARATIVE
  DIAGNOSIS.
• When a symptom(s) is followed by
  contrasting/comparative diagnoses, the symptom
  code is sequenced first. All the
  contrasting/comparative diagnoses should be coded
  as additional diagnoses.

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Selection of Principal Diagnosis

• ORIGINAL TREATMENT PLAN "NOT" CARRIED OUT.
• Sequence as the principal diagnosis the
  condition, which after study occasioned the
  admission to the hospital, even though treatment
  may not have been carried out due to unforeseen
  circumstances.
• COMPLICATIONS OF SURGERY AND OTHER MEDICAL CARE.
• When the admission is for treatment of a
  complication resulting from surgery or other
  medical care, the complication code is sequenced
  as the principal diagnosis. If the complication
  is classified to the 996-999 series and the code
  lacks the necessary specificity in describing the
  complication, an additional code for the specific
  complication should be assigned.

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Selection of Principal Diagnosis

• UNCERTAIN DIAGNOSIS
• If the diagnosis documented at the time of
  discharge is qualified as "probable",
  "suspected", "likely", "questionable",
  "possible", or "still to be ruled our", or other
  similar terms indicating uncertainty, code the
  condition as if it existed or was established.
  NOTE This guideline is applicable only to
  inpatient admissions to short term, acute,
  long-term care and psychiatric hospitals.

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Selection of Principal Diagnosis

• ADMISSION FROM OBSERVATION UNIT
• 1. Admission Following Medical ObservationWhen
  a patient is admitted to an observation unit for
  a medical condition, which either worsens or does
  not improve, and is subsequently admitted as an
  inpatient of the same hospital for this same
  medical condition, the principal diagnosis would
  be the medical condition which led to the
  hospital admission. 2. Admission Following
  Post-Operative ObservationWhen a patient is
  admitted to an observation unit to "monitor" a
  condition (or complication) that develops
  following outpatient surgery, and then is
  subsequently admitted as an inpatient of the same
  hospital, hospitals should apply the Uniform
  Hospital Discharge Data Set (UHDDS) definition of
  principal diagnosis as that condition
  established after study to be chiefly responsible
  for occasioning the admission of the patient to
  the hospital for care."

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Selection of Principal Diagnosis

• ADMISSION FROM OUTPATIENT SURGERY
• When a patient receives surgery in the hospital's
  outpatient surgery department and is subsequently
  admitted for continuing inpatient care at the
  same hospital, the following guidelines should be
  followed in selecting the principal diagnosis for
  the impatient admission.
• If the reason for the inpatient admission is a
  complication, assign the complication as the
  principal diagnosis.
• If no complication, or other condition, is
  documented as the reason for the inpatient
  admission, assign the reason for the outpatient
  surgery as the principal diagnosis.
• If the reason for the inpatient admission is
  another condition unrelated to the surgery,
  assign the unrelated condition a s the principal
  diagnosis.

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REPORTING ADDITIONAL DIAGNOSIS

• For reporting purposes the definition for other
  diagnoses is interpreted as additional
  conditions that affect patient care in terms of
  requiringclinical evaluation ortherapeutic
  treatment ordiagnostic procedures orextended
  length of hospital stay. orincreased nursing
  care and/or monitoring.The UHDDS defines "other
  diagnosis" as "all conditions that coexist at the
  time of admission, that develop subsequently, or
  that affect the treatment received an/or the
  length of stay. Diagnosis that relate to an
  earlier episode which have no bearing on the
  current hospital stay are to be excluded." UHDDS
  definitions apply to inpatients in acute care,
  short-term, long term care and psychiatric
  hospital setting. The UHDDS definitions are used
  by acute care short-term hospitals to report
  impatient data elements in a standard manner.

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REPORTING ADDITIONAL DIAGNOSES

• The following guidelines are to be applied in
  designating there diagnoses when neither the
  Alphabetic Index nor the Tabular List in the
  ICD-9-CM provide direction. The listing of the
  diagnosis in the patient record is the
  responsibility of the attending provider.A.
  Previous conditionIf the provider has included
  a diagnosis in the final diagnostic statement,
  such as the discharge summary or the face sheet,
  it should ordinarily be coded. Some providers
  include in the diagnostic statement resolved
  conditions or diagnoses and status-post
  procedures from previous admission that have no
  bearing on the current stay. Such conditions are
  not to be reported and are coded only if required
  by hospital policy.However, history codes
  (V10-19) may be used as secondary codes if the
  historical condition or family history has an
  impact on current care or influences treatment.

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ABNORMAL FINDINGS

• Abnormal findings (laboratory, x-ray,pathologic,
  and other diagnostic results) are not coded an
  reported unless the provider indicates their
  clinical significance. If the findings are
  outside the normal range and the attending
  provider has ordered other tests to evaluate the
  condition or prescribed treatment, it is
  appropriate to ask the provider whether the
  abnormal finding should be added.

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UNCERTAIN DIAGNOSIS

• If the diagnosis documented at the time of
  discharge is qualified as "probable",
  "suspected", "likely", "questionable",
  "possible", or "still to be ruled out" or other
  similar terms indicating uncertainty, code the
  condition as ...IF IT EXISTED -OR- WAS
  ESTABLISHED. NOTE This guideline is only
  applicable to inpatient admissions to short-term,
  acute, long-term care, and psychiatric hospitals.
  

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Procedures

• In accordance with UHDDS definitions, all
  significant procedures are to be reported.
• A significant procedure is one that is (1)
  surgical in nature, or (2) carries a procedural
  risk, or (3) carries an anesthetic risk, or (4)
  requires specialized training.
• When more than one procedure is reported, the
  principal procedure is to be designated. In
  determining which of several procedures is
  principal, the following criteria apply
• The principal procedure is one that was performed
  for definitive treatment rather than one
  performed for diagnostic or exploratory purposes,
  or was necessary to take care of a complication.
• If there appears to be two procedures that are
  principal, then the one most related to the
  principal diagnosis should be selected as the
  principal procedure.

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UHDDS Definitions - continued

• Reportable Diagnoses/Procedures. To achieve
  consistency in the coding of diagnoses and
  procedures, all individuals who are authorized to
  perform coding/claims processing of inpatient
  services (Coding Personnel) must
• Thoroughly review the entire medical record as
  part of the coding process in order to assign and
  report the most appropriate codes.
• Adhere to all official coding guidelines as
  approved by AHA, AHIMA, CMS and NCHS
  (Cooperating Parties).
• Observe sequencing rules identified by
  Cooperating Parties.
• Assign and report codes, without physician
  consultation/query, for diagnoses and procedures
  that are not listed in the physicians final
  diagnostic statement only if those diagnoses and
  procedures are specifically documented in the
  body of the medical record by a physician
  directly participating in the care of the
  patient, and this documentation is clear and
  consistent

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UHDDS Definitions - continued

• Reportable Diagnoses/Procedures
• Areas of the medical record which contain
  acceptable physician documentation to support
  code assignment include the discharge summary,
  history and physical, emergency room record,
  physician progress notes, physician orders,
  physician consultations, operative reports,
  physician notations of intraoperative occurrences
  and other ancillary, diagnostic reports signed by
  physicians (such as anesthesia report, pathology
  report)
• When diagnoses or procedures are stated in other
  medical record documentation by non-physicians
  (nurses notes, MDS abstract (SNUs), pathology
  report, radiology reports, laboratory reports,
  EKGs, nutritional evaluation and other ancillary
  reports), the attending physician must be queried
  for confirmation of the condition. These
  conditions must also meet the coding and
  reporting guidelines outlined in AHA Coding
  Clinic, 2Q, 1990 page 12.

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UHDDS Definitions - continued

• Reportable Diagnoses/Procedures
• Utilize medical record documentation to provide
  specificity in coding, such as utilizing the
  radiology report to confirm the fracture site or
  referring to the EKG to identify the location of
  an MI.
• Consult the physician for clarification when
  conflicting or ambiguous documentation is
  present. Ask the physician to add information to
  the record before assigning a code that is not
  supported by documentation

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Query Process

• Coding Personnel should query the physician once
  a diagnosis or procedure has been determined to
  meet the guidelines for reporting but has not
  been clearly or completely stated within the
  medical record by a physician participating in
  the care of the patient or when ambiguous or
  conflicting documentation is present.
• All facilities should educate their physicians
  on the importance of concurrent documentation
  within the body of the medical record to support
  complete, accurate and consistent coding.

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Query Process

• Communication should be provided to the medical
  staff that individuals responsible for coding
  patient diagnoses or procedures will query
  physicians when there are questions regarding
  documentation for code assignment. The
  physicians response to the query should be
  signed by the physician and become part of the
  medical record. The facility itself should
  determine if the actual coding query will be
  maintained as part of the medical record.
• Coding Personnel must not suggest a code or
  medical record documentation that is not
  supported by the patients clinical presentation
  and/or condition. Coding Personnel may relate to
  physicians what the particular documentation
  requirements are for specific codes, and the
  physician can then make the appropriate
  documentation decision based upon the patients
  clinical presentation and/or condition.

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Data Quality Application

• Coding Personnel must not
• Add diagnosis codes solely based on test results,
  unless diagnosis is obtained from physician
  through the query process.
• Misrepresent the patients clinical picture
  through incorrect coding or adding
  diagnosis/procedures unsupported by the
  documentation for any reason.
• Report diagnoses and procedures that the
  physician has specifically indicated he/she does
  not support.

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Facility Coding Reviews Audit findings

• Internal (or external) coding quality reviews
  must be completed on a regular basis by each
  facility.
• Reviews should include review of the medical
  record to determine accurate code assignment with
  subsequent comparison with the UB-04 claim form
  to determine accurate billing.
• Findings from these reviews must be utilized to
  improve coding and medical record documentation
  practices and for Coding Personnel and physician
  education, as appropriate.

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Questions ..