Coding Reviews Can Be Complex

Today, I want to focus on quality review for facility coding. A best practice is to have an external review performed annually, but what should the reviewers be assessing? Remember that coding is more than just health information management (HIM).

Here are some topics that should be included in the review:

1. Are coders following your facility coding guidelines? You have established guidelines to capture the data that is needed by the facility, so include your facility-specific coding guidelines with your review.
2. What about diagnosis and procedure mismatch Diagnosis-Related Groups (DRGs) 981-983 and 987-989? What is the frequency of these DRGs? Has the frequency changed over the past five years? Audit a sample of these DRGs to confirm that the principal diagnoses and procedures are accurate.
3. How many DRGs without complication/comorbid conditions (CCs) or major complication/comorbid conditions (MCC) being captured? You want to trend your CC/MCC capture rate. Has that rate changed over recent years? Can you explain the changes, such as new service, elimination of a service, the pandemic, etc.? Include a sample of these DRGs in your inpatient review.
4. Review payor denials. Is there a trend in subjects with conditions such as sepsis, acute respiratory failure, hyponatremia, etc.? Are the cases appealed? Do you have success on appeal? Denials can be used to identify areas where documentation can be improved. A sample of payor denials can be included in your annual review to confirm any documentation issues.
5. Denials based on charges such as missing implant or unlisted codes. I think that a coder can assist in determining if codes in the chargemaster are accurate. HIM can verify if medical records have been sent to validate implants, infusions, injections, or other services. If you are not documenting all the medical records that are provided to the payors, then you may want to change this process. Additionally, you may want to establish a monthly meeting to review charge denial trends to determine if there is a fix for the issue available.
6. Review the emergency department (ED) visit distribution. Does the distribution for 99281-99285 look like a bell curve? If not, can you explain the variation? If the curve has a shift, then you could be losing money. An analysis of the ED-level assignment should be included in your annual review.
7. Quality data involves coding. Is their data like your data? Do they have any data gaps? One example is regarding peripherally inserted central catheter (PICC) lines. If the HIM coders are not assigning codes for PICC lines, then quality will not see any information regarding those measures that involve the use of PICC lines.

Coding is a complex topic, so you should ensure that your annual analysis encompasses HIM coding, ED levels, clinical documentation integrity, quality measures, and chargemaster. The results will impact your revenue cycle.

It is important to share the results with the other functions at the hospital so that all facility coding is accurate and supported by the medical documentation.