RIMR offers offsite inpatient and outpatient reviews for coding accuracy and record integrity issues. The audit will focus on inpatient present on admission indicators, query concerns, and diagnosis accuracy as well as CPT and ICD-10 validation for outpatient surgical and Emergency Room charts and lastly ICD-10 validation for ancillary and observation charts.
Objectives
To provide inpatient and outpatient reviews with a focus on coding accuracy, documentation feedback, as well as patterns of concern as identified, by coder, by provider.
To provide feedback on individual coder accuracy and other record integrity issues impacting completeness of coding.
To present findings telephonically to provide direct feedback on patterns and educational elements while resolving questions as presented.
Scope of project
All auditing will be done offsite with telephonic presentation of findings. The scope of the project is designed to be as flexible as possible allowing the hospital’s Health Information Manager to select areas for audit as deemed necessary.
A thumb drive of the full medical record plus the hard copy UB and itemized statements will be submitted. However, it is anticipated that electronic access will be used if rapid and ongoing access is built with IT support available.
The site will determine the volume per coder, per patient type. It is recommended that each category/patient status include a 20-chart audit based on high risk, complications, repeat queries, and other coder/provider challenges. (EX: one coder doing both inpatient and outpatient: 20 inpatient, 20 outpatient = 40 total chart audit.)
Coder: Identify number of coders with 20 chart audit per coder.
To conduct a COMPARISON benchmark audit for both inpatient and outpatient claims focusing on:
Inpatient: Present on Admission, query concerns, and diagnosis accuracy (if used)
– using known ‘high risk’ diagnoses, the site will identify an audit sample. All coding changes will be identified, by coder, by patient type.
All outpatient surgical: CPT and ICD-10 validation
Ancillary: ICD-10 validation
Observation: ICD-10 validation
ER: ICD-10, CPT validation
Deliverables
Audit results will include accuracy of coding, patterns, and documentation vulnerabilities. Results will be discussed with leadership which include recommendations for improvement per coder and patient type. The provider will also be identified in the audit findings.
An Executive Summary will be presented telephonically within 45 days with telephonic presentation of findings. Please allow 1.5 hours for the presentation.
Full patient/coder detail will be provided and referenced as teaching examples during the presentation of finding’s call.