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70 Cards in this Set
- Front
- Back
7 Criteria for quality documentation |
1. Legible - clear enough to be read and deciphered 2. Reliable - trustworthy, safe, able to be repeated 3. Precise - accurate, exact, strictly defined (detailed) 4. Complete - maximum content, thorough covering all concerns 5. Clear - not vague 6. Consistent - not contradictory 7. Timely |
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OIG minimum documentation compliance for a health record |
1. Complete and legible 2. Past and present diagnosis 3. Health risks factors identified 4. Rationale for diagnostic tests and ancillary services 5. Documented patient response and changes in treatment, revisions in diagnosis 6. Documentation for each encounter includes reason for the encounter, relevant history, exam findings, diagnostic test results, clinical impression, diagnosis and plan of care |
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Outpatient documentation issues |
1. Lack of clarity 2. Medical necessity not met 3. limited supply of outpatient coders and usually they have the least amount of experience |
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Definition - Principal Diagnosis |
Inpatient - condition, after study, that is determined to have caused the admission |
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Definition - Secondary Diagnosis |
Inpatient - All other conditions clinically evaluated, treated and tested during the stay or responsible for increasing the LOS or using other resources |
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DRG system |
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Definition - POA |
Is the condition Present on Admission, started in 2007, used to help determine severity and intensity of resources needed for the hospital admission
If the Diagnosis is not POA, it is considered a quality concern for the hospital and is not considered in severity and intensity for payment/DRG selection |
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FY 2015 for Coding |
October 2014 to September 2015 |
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Cooperating Parties for ICD-9 |
1. CMS - procedure side 2. NCHS National Center for Health Statistics- Diagnosis 3. AHA American Hospital Association - coding clinic and guidelines 4. AHIMA - education |
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Definition UHDDS |
Uniform Hospital Discharge Data Set - requires that all significant procedures be reported
significant = Is surgical in nature, carries a procedural risk, carries and anesthesia risk, requires specialized training |
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Definition Principal Procedure |
That which was performed for definitive treatment rather than for diagnostic or exploratory purposes or for treatment of a complication. |
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Cancelled Procedure Coding |
1. If a cavity or space was entered, assign a code describing the exploratory procedure for that site 2. If an incision was made, assign a code describing the incision for that site 3. If a closed fracture reduction was attempted and aborted, no procedure code is assigned (use V64) - a failed procedure is a completed procedure 4. If a procedure is cancelled before it begins, no procedure code is assigned 4. If a procedure |
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Incomplete Procedure Coding |
1. When a cavity or space is entered, code exploration of the site 2. When the endoscopic approach is used, but the definitive procedure could not be carried out, code the endoscopy only 3. When only an incision is made, code the site of the incision 4. When the procedure does not involve an incision, no procedure code is assigned |
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MS-DRG represent/goals |
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MS-DRG formula (how to calculate payment) |
DRG Relative weight (same for everyone nationwide) Hospital Base rate (varies by hospital)
DRG RW * Base rate = hospital payment |
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Items impacting MS-DRG assignment |
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CPT Code |
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What are HCPCS Codes |
Level 1 are CPT codes Level 2 are local codes, drugs, DME, etc and maintained by CMS |
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Who are users of Health Information |
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Steps in the Communication Process |
Sender Message Medium (How sent) Receiver |
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CDI training program objectives |
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AHIMA's role as a participating party |
American Health Information Management Association - education and advocacy |
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Who sets the Standards |
ICD - International Classification of Diseases WHO - World Health Organization NCHS - National Center for Health Statistics |
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Cooperating Parties |
AHA - American Hospital Association AHIMA - American Health Information Mgmt Assoc. NCHS - National Center for Health Statistics CMS - Cetner for Medicare and Medicaid Services |
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AHIMA's role as cooperating party |
Education |
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AHA's role as cooperating party |
Clearinghouse for issues related to ICD-9 Publishes Coding Clinics |
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NCHS's role as cooperating party |
Diagnosis side of ICD |
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CMS's role as cooperating party |
Regulations regarding quality and reimbursement |
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OIG |
Office of Inspector General - work plan each year showing focus areas (target area)
Developed in 1976 and is part of HHS |
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AHRQ current focus areas |
Agency for Healthcare Research and Quality 1. Prevention Quality Indicators 2. Inpatient Quality Indicators 3. Patient Safety Indicators 4. Pediatric Quality Indicators |
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IPPS quality measures |
mandatory data submission acute myocardial infarction (AMI) heart failure (HF) Pneumonia (PN) Surgical care improvement project (SCIP) 30 day mortality rates for AMI, HF and PN |
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Outpatient OPPS Measures |
Created by 2006 Tax Relief and Health Care Act, contains 119 measures |
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NPSG |
National Patient Safety Goals - Joint Commission 15 measures |
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QI process |
This is a circular process Identify performance measures Start measuring Look at data - analyze Identify improvement opportunities Continually Monitor |
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Other names for Performance Improvement (PI) |
CQI - Continuous quality improvement TCM - total quality management |
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What is a Mission Statement |
Short description of the general purpose of an organization or group Explains why the organization exists Usually includes a broad definition of the services provided |
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What is a Vision Statement |
Short description of the organization's future ideal state. Is idealistic and futuristic |
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What is a Value Statement |
Supports the behavior of the organization Promotes social and cultural beliefs Ethics statement |
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4 stages to team building |
1. Forming - people start to work together and make an effort to get to know their colleagues 2. Storming - people start to push against the boundaries established in the last phase, many teams fail at this stage; question the worth of the team's goals 3. Norming - people being to resolve differences, appreciate strengths of other team members 4. Performing - the team is work on the goal |
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FOIA |
Freedom of Information Act - first privacy law in US; applies to federal agencies |
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Privacy under HIPAA |
1. Sets a federal "floor" for privacy 2. Limits how information can be used or disclosed 3. Gives rights to individuals 4. Civil penalties 5. Enforced by the Office of Civil Rights (OCR) 6. Patients can request amendment to information (accounting of disclosures) |
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Security under HIPAA |
1. Who has access to information 2. national standard for electronic information 3. Administrative, physical and technical safeguards 4. Security measures when disclosing information |
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Administrative, Physical and Technical Safeguards Under HIPAA |
Admin - identify/analyze risks; staff training; limiting access; contingency planning Physical - facility access controls; workstation security; workstation policies Technical - access controls to PHI; audit controls; integrity controls; transmission security measures |
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HIPAA breach definition |
An impermissible use or disclosure under the Privacy Rule that compromises the security or privacy of PHI |
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Fraud and Abuse Definition |
Fraud - Intentional deception or misrepresentation that an individual knows to be false or does not believe to be true and makes, knowing that deception could result in some unauthorized benefit to himself or other person Abuse - activity where someone overuses or misuse service |
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Fraud and Abuse Monitoring |
PPACA - Patient Protection and Affordable Care Act created new fraud tools and expanded definition of improper conduct Title XI (11) of the Social Security Act - exclusion from the federal payer program if convicted of misconduct |
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What are "red flags" for auditors (compliance) |
Repeated provider errors Annual code updated (are the providers using the updates) New Payer requirements (reimbursement changes) |
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4 components of a compliance plan |
1. Policy and Procedure Development 2. Program Monitoring (validity of queries, working DRG assignments, missed query opportunities) 3. Auditing 4. Follow up education |
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What information should be included on a query? |
Patient Name Admission date/date of service Health record number Account number Date of query Name/contact info for response to query Statement of the issue (open ended, multiple choice) should not be yes/no |
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What information should be included in the Statement of the Issue in a query? |
Should be written as a question - clinical indicators from the chart - as the provider to make a clinical interpretation of the facts in the chart -query format should not sound presumptive, directing, prodding, proving or as though the provider is being led to a diagnosis |
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New information in a query |
Introduction of new information not previously documented is inappropriate
can say patient is on XYZ medication, is there a diagnosis dr. says fracture, radiology report gives more details on location, can query the doctor a yes/no question on location |
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Yes/No Queries |
should be avoided where possible POA is the exception |
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Multiple choice queries |
Make as open ended as possible -Clinically relevant/reasonable choices should be listed - Also need to include "other"; "Unable to determine"; and "clinically irrelevant" -Be sure to give a line (place) for the doctor to specify information in the "other" answer |
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Is a query needed? |
Does the patient's record have: -conflicting information -ambiguous information -incomplete information -clinically relevant information -regards any significant reportable condition or procedure, if yes, query |
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Indicators when a query is needed |
- record not legible -record not complete, missing test results, missing a progress note, etc - clarity issues- diagnosis documented without documentation of cause or suspected cause - can't determine POA - consistency (differing information between providers) |
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Timing of a query |
Concurrent - CDI is usually concurrent Retrospective - coding is usually completed here - post bill - most often completed after an audit (external or internal)
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When not to query |
-when the benefit is strictly for reimbursement - no clinical evident to support a query - when facility guidelines state not to query - clinically insignificant findings or irrelevant information shouldn't result in a query |
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examples of key metrics for CDI program
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Top DRG Conditions most often queried Record review rate Physician query rate Physician response rate validation rate - are the right questions being asked |
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Examples of CDI program goals |
effective and efficient developed specifically by the organization guided by key metrics (Indicators) clinical documentation captures SOI and ROM clarify missing/incomplete/conflicting documentation supports accurate diagnosis promote patient safety through a complete record |
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4 types of categorical data |
1. Nominal - values fall into unordered categories (true/false; male/female) 2. Ordinal - values are ordered categories or are ranked (0-10 scale) 3. Ranked - arranged highest to lowest and then assigned numbers that correspond to each observation's place in the sequence (top 4 leading causes of death) 4. Interval - units of equal size (IQ scores) |
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2 types of numerical data |
1. discrete - finite number (How many in household, the number of new AIDS cases) 2. Continuous - measurable quantities (blood pressure, serum cholesterol) |
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ways to display data |
Table - columns/rows used for all types of data; summarizing a set of observations Bar Graph - frequency distribution for nominal or ordinal data Histograms - frequency distributions for continuous (interval or ratio data) Line Graph relationship between continuous quantities (patterns/trends) Pie chart - components as part of a whole |
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Recommended data capture items |
discharge by service discharge by DRG discharge by Major Diagnostic Category (MDC) Case Mix index Complication rate severity level Medicare quality indicators |
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how to calculate denial rate |
number of claims denied divided by the number of claims submitted |
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tracking queries |
query rate = number of queries divided by number of records reviewed
track by physician, response rate, validation rate |
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What is the definition of Case Mix Index CMI |
the average DRG relative weight for inpatient cases, is an indicator of average reimbursement per patient |
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What might impact a change in the Case Mix Index |
seasonal variations (flu, pneumonia) medical and surgical mix physician staffing changes coding competency SOI among the patient population |
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PPS - prospective payment system concepts |
1972 Establish payment rates in advance and apply as "fixed" Rates not automatically determined by the hospital's past or current cost Payment is payment in full Hospital retains profit or loss |
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PPS inpatient includes? |
Acute care hospital
excludes: psych units; long term care unit; rehab units |
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PPS types (examples) |
IPPS - Acute inpatient - DRG OPPS Hospital outpatient APC HH Home Health OASIS SNF Skilled Nursing Facility MDS IRF Inpatient Rehab facility |