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Clinical Documentation and Coding:The Way Forward

CAPT Rebecca McCormick-BoyleAssistant Deputy Chief, Current Operations, BUMED M3B

The Process: From Clinical Documentation to Decision Making

ResourcingPopulation

Health & Clinical Quality

INPUTS

OUTPUTS

Clinical Documentation

Coding

Clinical Documentation & Coding: Decision Making Examples

Population Health & Clinical Quality– HEDIS Measures– Illness & Injuries Frequency & Trends– Force Health Protection & Readiness– Research– Risk Management

Resourcing– Business Case Analysis– Service Line Development– Manpower Assessment– Funding Review– Equipment Plans– PPS earnings

Oct Nov Dec Jan Feb Mar Apr May June July Aug Sept

75%

80%

85%

90%

95%

6d. Outpatient %CPT Coding Correct

Army Navy Air Force Svc Avg

Clinical Documentation & Coding:DQMC Assessment

Oct Nov Dec Jan Feb Mar Apr May June July Aug Sept

80%

85%

90%

95%

100%6c. Outpatient % ICD-9 Coding Correct

Army Navy Air Force Svc Avg

Oct Nov Dec Jan Feb Mar Apr May June July Aug Sept

75%

80%

85%

90%

95%

6b. Outpatient % E&M Coding Correct

Army Navy Air Force Svc Avg

Financial recapture opportunity: $61M – Relative Weight Products: $26M by standardizing the provider query

process and increasing provider and coder communication.– Evaluation and Management coding: $8M in physical exams.– Ambulatory Procedure codes: $27M through placement in the correct

Medical Expense and Performance Reporting System Population health opportunities:

– HEDIS/ Population Health: Gestational diabetes vs chronic diabetic– Procedural data: 1000 cc vs. 1 cc of a pharmaceutical product– Procedural data: 900 procedures vs. 1 procedure provided– Procedural data: Abortions - elective vs. spontaneous

Issues:– Training: #1 reason Navy-wide for DQMC coding deficiencies– Staffing: Numbers; coding competency and MATO contract concerns– Process: Adherence to standard coding audit guidelines– Technology: AHLTA’s coding methodology (i.e., specialty care)

Clinical Documentation & Coding:Recovery Audit Assessement

“Just as a complete and accurate medical record coding promotes quality in healthcare delivery, complete and accurate medical record coding promotes quality and clarity in healthcare cost accountability.”

-Surgeon General’s Policy Letter on Coding, 1 Oct 2010

Clinical Documentation & Coding:SG’s Assessment

Coding Program Standard Audit Guidelines, 23 Feb 10

SG’s coding policy letter, 1 Oct 10

HIM coding guidance letter, 8 Nov 10

Navy Medicine coding survey, 24 Nov 10

Project Management Office, 10 Dec 10

MATO Policy Letter, 10 Dec 10

Audit Registry Prototype Letter, 23 Dec 10

Regional Assessment Letter, 14 Dec 10

Clinical Documentation & Coding:Action Plan & Guidance

Standardize Audit Process

Regional Assessment Visits

Query Process:– Provider – coder communications

Personnel processes– Position Descriptions, Performance incentive, Contracting

Training– Standardized and centralized

E&M Code Guidance– Physical exams in particular (well vs. established)

Clinical Documentation & Coding:Program Management Office Action Steps

Review DQMC and coding processes

Involve clinical and admin leadership in DQMC review

Include PAD officer in the DQMC process

Engage PAD officer in reporting and action planning

Review audit findings (trend analysis)

Increase your audits:– Sample size > 30 minimum– Focused reviews/root cause analysis of DQMC statement error and

reason codes

Clinical Documentation & Coding:Recommended MTF Action Steps

Decision Making Based on Accurate Data

Strong Foundation for ICD-10 Implementation

Acknowledge the importance of our clinical staff’s valuable time and effort and our responsibility to invest in the resources needed to capture clinical documentation

Enhanced understanding of the health of those we serve

Clinical Documentation & Coding:The Goal