Case Study Audit Report

MRC135 Portfolio Project.1

Case Study Audit Report

Frank Skwierc

Bryant & Stratton College Online Campus

MRC 135 Diagnostic Coding

Instructor Catina L Flagg

October, 24, 2015

This Portfolio project is about Case Study Audit Reports and how documentation is the basis for coding. All health care providers are responsible for documenting and authenticating legible, complete, and in a timely manner all patient records in accordance with federal regulations. The provider is also responsible for correcting or altering errors in the patient record documentation. This type of documentation is needed to prove Medical Necessity for reimbursement to the regulating agencies. These documents can consist of three different formats, a manual record which is paper based an automated record which is computer based or a hybrid record which is a combination of both paper and computer. The information in the record must support codes submitted on claims reported for reimbursement. Things that should be included in the documentation are any services or supplies that are proper or needed for the diagnosis or treatment that was provided.

One way to insure that your documentation is accurate is to set up a coding compliance program that ensures that the assignment of codes to diagnoses, procedures, and services follow established coding guidelines such as those published by the CMS who write policies on what to do and procedures on how to do it. This will help you implement the five stages of coding compliance which are detection, correction, prevention, verification, and comparison. To make sure that everyone is following the coding compliance program you will want to conduct annual audits of these records by choosing some cases at random. Audits will help identify and correct problem areas before the provider is challenged with inappropriate coding that is supplied to insurance companies or the government.

The AAPC (American Academy of Professional Coders) explains that Medical auditing is a key step in the livelihood of a compliant and profitable practice and focuses on many areas of a practice to ensure medical necessity, correct coding, and compliance with regulatory issues are met. In an article put out by the AHIMA entitled How to lead your organization in compliance, ethics, and customer service it mentions a website put out by the Office of Inspector General that offers compliance guidance tailored to specific healthcare industries. These compliance programs that are created will then assist the CCS (certified coding specialist) or medical office manager, with the means to audit and monitor relevant ongoing organization operations.The most common example of this is in the area of billing and coding, where reviewing a sample of records helps ensure the documentation adequately supports the codes assigned. That is why auditing is a fundamental operation necessary in all compliance programs. Attached to this document are three case studies that will be carefully reviewed, because only part of the patient’s total record is available, there will be reason to determine if any additional documentation will be needed and if appropriate to lodge any questions to the physician in order to code these cases correctly and completely.

Case Study 1

Jessica Bowman a 28 year old female who is present in the ED (Emergency Department) Diagnoses Concussion with 5 minutes loss of consciousness ICD-9 code entered is 850.11, other Symptoms, Signs, and Ill-Defined Conditions reported in the Diagnoses are Shortness of breath Coded 786.05, Painful respiration Coded 786.52 and Rales Coded 786.7 also mentioned in the Diagnoses is what happen to her a fall from a horse (no collision) code E006.1 while horseback riding and the place the paddock at a horse farm code E849.1 Mentioning these Codes help back up the procedures ordered by the physician like Skull x-ray Coded 87.17, CBC and urinalysis coded V72.60, Chest x-ray two views Coded V72.5 All this explains the charge for Level 2 ED service. Some additional documentation needed would be on her pregnancy to help explain three times pregnant but only to term twice since she does state that she is past her due date for her menstrual cycle this could have a bearing on the Diagnoses. Last a good question for the physician, is since the patient was treated within 24 to 48 hours of the concussion, it would be good to clarify with the physician whether the concussion is still in the acute phase or is it a post-concussion syndrome. This too may affect the way it is coded.

Case Study 2

Alicia Schwartz, age 10 was brought in the clinic by her mother who stated that the accident occurred while cleaning a bathroom in a resident she does housekeeping for. Here the coder supplied ICD-9 code E849.0 as the location of the accident. An examination revealed the skin of the ear was blistering, indicating a second degree burn coder assigned ICD-9 code 941.21 for the principal diagnosis. The burn treatment protocol required the following procedures to be performed a Sodium Chloride irrigation of wound coded 96.59 the application of antibiotic ointment coded 960.9 and the application of a 6x6 gauze pad coded 93.57. The patient was discharged home with aftercare instructions. Some addition documentation needed to code this out properly would be a detailed list of the instructions given to the patient for aftercare. Since the total time spent with the patient and her family is mentioned this will help justify the charge for the E/M services that were provided.

Case Study 5

Mr. Sutton age 87 who has registered for treatment in the cardiac catheterization lab. Because the patient has a history of a right heart congenital anomaly that was previously corrected, the coder coded ICD-9 V13.65 for this condition. In the morning he told his physician while in the office that he has pain in his chest and shoulder which travels down his left arm. The coder assigned ICD-9 code 413.9 for angina along with code 786.50 chest pain unspecified. These codes help explain why an ECG code 89.52 was preformed revealing the patient was experiencing a myocardial infarction. The patient was then diagnosed with acute myocardial infarction the coder assigned ICD-9 code 410.82 as the principal diagnosis. The patient was immediately scheduled for right heart catheterization that day. The procedures where Right heart cardiac catheterization coded 37.21 with measurements of oxygen saturation and cardiac output coded 89.67. The document goes on to explain briefly how the procedure was done and when the measurement of oxygen saturation and cardiac output were obtained. Additional documentation needed would be for the type of follow up care and treatment plan that was provided upon Mr. Sutton’s release.

Too often coders face difficulty in completing the coding process because of the lack of proper documentation. Documentation is the key to proper reimbursement, and the medical records used need to contain a variety of things so that a coder can code to the highest level. Doctor’s notes, laboratory results, radiology results and more are needed to properly code for reimbursement for diagnoses and procedures rendered by a health care provider. Even the American Academy of Professional Coders state that Quality health care is based on accurate and complete clinical documentation in the medical record. They go on to say that the only way to achieve this level of accuracy in your coding and documentation is to perform medical record audits. Audits such as these are designed to evaluate procedural and diagnosis code selection based on physician documentation. The article goes on to mention several benefits to doing medical audits one of the benefits spoke of remedying undercoding and reducing bad unbundling habits and code overuse so that you can bill appropriately for documented procedures. While medical audits can help improve the way you keep and document your records it still boils down to accurate medical records and documentation as the only sure fire way to prove Medical Necessity for all your claims.

References

Burton, B. (2014). How to Lead Your Organization in Compliance, Ethics and Customer

Service. Journal of AHIMA, 85(8), 22-25 4p.

American Academy of Professional Coders. (2015)., What is Medical Auditing? Retrieved on

Oct. 07, 2015. At <

Green, M. A., (2014). 3-2-1 Code It! (4thed.). Delmar, Cengage Learning. Clifton Park, NY.