Inpatient Coding Services
During inpatient coding reviews, our certified coding professionals perform a review of coded data and medical record documentation to identify and assess areas of risk related to compliance and specific targeted areas driven by the Recovery Audit Contractors (RAC), Medicare Administrative Contractors (MAC), Case Mix Index (CMI), Office of Inspector General (OIG) work plan, and/or any trends that we have identified.
What This Service Includes
Specific areas audited include the following:
- Appropriate assignment of ICD-9-CM principal and secondary codes
- Appropriate assignment of procedure codes
- Appropriate sequencing
- Appropriate application of coding guidelines
- Appropriate assignment of the DRG
- Appropriate discharge disposition status code
- Present on admission status indicator application
- Documentation opportunities: Identify gaps for MS-DRGs; identify reason for gaps and recommendations to bridge the gaps
How You Can Benefit From This Service
Comprehensive Medical Record Review by our certified coding professionals enables our clients to:
- Identify appropriate reimbursement adjusting under or over coding
- Identify potential complication/co-morbidity opportunities
- Provide a statistical breakdown of overall coding errors (up and down), as well as coding errors by individual coder (if name is provided)
- Identify official coding guidelines applicable to the findings and develop focused educational efforts
- Identify potential opportunities due to documentation gaps for the Concurrent Documentation Program (CDP)
- Identify physician legibility issues
- Educate medical staff
Key Performance Indicators
Inpatient Coding Reviews include the following key performance indicators (KPI):
Present on Admission (POA)
POA is defined as present at the time the order for inpatient admission occurs – conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery, are considered POA.
POA is a required coding component that assists in identification of Hospital Acquired Conditions (HACs).
Discharge Disposition Codes
A disposition code indicates the patient’s status as of the “through” date of the billing period and are required by CMS for all Part A inpatient, SNF, hospice, home health agency and outpatient hospital services.
Physician Query Opportunities
AHIMA brief “Managing an Effective Query Process” indicates that “Providers should be queried whenever there is conflicting, ambiguous, or incomplete information in the health record regarding any significant reportable condition or procedure” or if “additional information is needed for correct assignment of the POA indicator.”
Managing query opportunities enables hospitals to achieve accurate coding that in turn allows for accurate patient resource consumption and severity of illness.
Sequencing
Sequencing the most pertinent and significant diagnoses/procedures in the top nine diagnosis and six procedure fields will allow for the most appropriate coding and accurate DRG reimbursement.