Transforming Coders to Auditors Inpatient Auditing – Who...

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Transforming Coders to AuditorsInpatient Auditing – Who, What, and Why?

Laurie A. McBrierty, MLT ASCP

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Speaker Introduction

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LAURIE MCBRIERTY

VICE PRESIDENT, PRODUCT MANAGEMENT

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Experienced, online adult-focused healthcare education company for 25 years

• Educated more than 108,000 learners

• Continuing Education subscriber base is over 250, 000 learners

• Providing programs for over 175 academic partners

Focused on employment advancement and professional development

Deliver products across the healthcare continuum- administrative, clinical, and revenue cycle management

Career StepFocused in Healthcare Education

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Career StepContinuing to Expand

Continue to expand our existing 57 product portfolio with a focus on innovative, engaging programs and services

• Revenue Cycle Management provides education solutions in coding refresher education, data analytics and consulting.

• EMS Platform and Solutions are CAPCE approved and NREMT accepted,

• Continuing education in emergency life support, ACLS, BLS, PALS

Career Step is the premier provider of career-focused healthcare education and training solutions. We

remain focused on improving lives, advancing careers, and driving business results through education.

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• Discuss drivers of inpatient auditing

• Understand the role of an inpatient auditor and what makes a good one

• Learn how to build your inpatient audit team

• Learn about the types of auditing and when, during the revenue cycle, they are performed

• Understand the 3-C approach to auditing

• Understand the three-part Career Step approach

Agenda

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• Changes in reimbursement models

• Increase in regulatory audits

• Rise in DRG downgrading

• Increased regulatory reporting requirements

Drivers

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Percent of Participating Medical/Surgical Acute Hospitals with RAC Activity Experiencing Complex Denials by Reason, through 3rd Quarter 2016Survey participants were asked to select all reasons for denial.

Most Commonly Cited Reason For Complex Denial: Inpatient Coding Error

7http://www.aha.org/content/16/16q3-ractracresults.pdf

Source: http://www.aha.org/content/16/16q3-ractracresults.pdf

Top Reasons for Complex Denials

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What drivers are you seeing for Inpatient Auditing?

Poll Question #1

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Role of the Auditor

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Inpatient Auditor’s Responsibility

• Ensure documentation and coding are to the highest level of specificity

• Ensure correct code assignment

• Ensure optimal DRG assignment

• Ensure coding is compliant

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Role of Inpatient Auditor

• Review clinical information to validate proper code and DRG assignments

• Identify coding and documentation concerns

• Classify the issues/problems

• Analyze and synthesize audit results and identify trends and patterns

• Make recommendations that will lead to improvements and resolutions

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Role of Inpatient Auditor

• Compile the findings of the audit

• Communicate the results of the audit

• Provide feedback to upper and middle management as well as coders

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Benefits of Auditors

• Optimize reimbursement driving coding and DRG accuracy

• Minimize at-risk revenue by identifying potential coding compliance risks

• Mitigate denials by conducting prospective audits to get the bill right the first time

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Types of Auditing

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Timing of Audits

• Prospective Pre-Bill – Performed after coding but before billing

– Pre-Bill Review and Audit

– Get the bill right the first time

• Retrospective– Performed after coding and claim submission

– Payment may or may not have been received

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Denial Reversals

Source: http://www.aha.org/content/16/16q3-ractracresults.pdf

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% that had a denial reversed during 3rd

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Poll Question #2

Have you had denials in lasttwo quarters?

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Is the Audit Internal or External?

• Performed by hospital auditors or consultants

• Identifies possible risk areas• Creates baseline for ongoing

monitoring

Internal

• Performed by government agencies and non-government payers

• Investigates claims submitted by hospitals

• Focused on improper coding/billing

External

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Aud

iting

Coding

A Few Examples of Audit Types

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Aud

iting Coding

DRG


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• ICD-10-CM Official Coding Guidelines

• ICD-10-PCS Official Coding Guidelines

• UHDDS Definitions

• Coding Clinic

• Keep an eye toward highest legitimate reimbursement

Coding and DRG Optimization

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Audits are focused on underpayments– Resulting from changes as a result of regulatory

and payer audits

• Analyze data by specific DRGs – Coder-specific

– Physician-specific

– Specialty-specific

• Based on trending analysis, scope an audit that is focused on the identified problems

DRG Downgrading Audits

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• Analyze data by specific DRGs – Coder-specific

– Physician-specific

– Specialty-specific

• Based on trending analysis– Scope an audit that is focused on the

identified problems

• Educated for improvement

How does auditing help DRG downgrading

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Poll Question #3

Have you seen DRG downgrading?

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Aud

iting Coding

DRG

Clinical Validation


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• Documentation specificity

• Documentation compliance

Documentation Improvement Audits

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Ready to build your team

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Building the team

1. Start with internal coder

2. Assess technical skills

3. Assess non-technical skills

4. Identify gaps

5. Educate and transform

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Assessing technical skills

• Evaluate coding productivity and accuracy

• Administer a coding skills assessment– Ensure consistent assessment

for all candidates

• Evaluate candidates understanding of official coding guidelines and Coding Clinics

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Assessing non-technical skills

• Assess the candidate’s communication skills

• Discuss the importance of fairness and objectivity when evaluating a colleagues work

• Assess problem-solving, decision-making, analytical, and high-level thinking skills

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Transform Coders to Auditors

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Inpatient

Auditor

Investigator

Problem Solver

Appraiser

Health Law and

Guidelines

Analyzer

Communicator

Coder

Coders and Auditors

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Inpatient

Auditor

Investigator

Problem Solver

Appraiser

Health Law and

Guidelines

Analyzer

Communicator

Coder

Coders and Auditors

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Inpatient

Auditor

Investigator

Problem Solver

Appraiser

Health Law and

Guidelines

Analyzer

Communicator

Coder

Coders and Auditors

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Inpatient

Auditor

Investigator

Problem Solver

Appraiser

Health Law and

Guidelines

Analyzer

Communicator

Coder

Coders and Auditors

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Inpatient

Auditor

Investigator

Problem Solver

Appraiser

Health Law and

Guidelines

Analyzer

Communicator

Coder

Coders and Auditors

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Inpatient

Auditor

Investigator

Problem Solver

Appraiser

Health Law and

Guidelines

Analyzer

Communicator

Coder

Coders and Auditors

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Inpatient

Auditor

Investigator

Problem Solver

Appraiser

Health Law and

Guidelines

Analyzer

Communicator

Coder

Coders and Auditors

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Plus Important Soft Skills

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How are you improvingsoft skills today?

Poll Question #4

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Career Step’s 3 C’s of Inpatient Auditing

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Capture

Compute

Communicate

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Capture

Worksheet

Documentation Deficiencies

Notes and Citations


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Compute

Review and Summarize Your Worksheet

Changes Reimbursement

Notes -citations etc.


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Communicate

Write Report

Prepare Presentation

Deliver Presentation


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Capture

Compute

Communicate

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How do you Transform Coder to Auditor?

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Solid Coding Skills

• 3 years of coding experience – Acute care inpatient setting in the last five years

• Maintained 95% accuracy in the last rolling 12 months

• Ability to maintain coding productivity standards

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Transforming

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Building Audit Knowledge

Reinforce fundamentals:

ICD-10, DRGs, Compliance and HIPAA, Healthcare Law

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Clinical Documentation Integrity and

ICD-10 Pitfalls and Case Studies


ICD-10, DRGs, Compliance and HIPAA, Healthcare Law

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Administrative Technical &

Soft Skills




ICD-10, DRGs, Compliance and HIPAA, Healthcare law

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Robust coverage of Audit Principles with Hands-on Practicum

Administrative

Technical & Soft Skills




ICD-10, DRGs, Compliance and HIPAA,

Healthcare Law

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Hands-On Auditing Experience

• Audit and Record Review

• Conducting the Audit

• Developing the audit report

• Communicating the audit results

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Best Practices for Educating Your Team

• Validate strength and weakness

• Educate on their time or yours

• Create individual learner paths for your team members

• Monitor progress

• Determine scoring options and configurations

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Ensure you have tools to lift administrative burden from your management team

Launching Inpatient Auditing Program

• Designed for adult learners

• Uses multiple modes

• Provides testing-out of first 6 courses

• Ensures solid practice: 50 to 100 cases audited

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Education Examples from the Program

Learners are introduced to

• Auditing concepts including statistical sampling

• Hard and soft skills development

• Communicating audit results

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Blended Rates

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Excel Skills

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Statistical Sampling

Sampling Goals:

• Close to the real value or true population – High confidence level

• Large enough to reduce random variability – Minimize the effect of outliers

• Small enough to be manageable

• Many articles and college-level statistics courses address these challenges

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Soft Skills Development

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Communicating Audit Results

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Download the sample Audit

worksheet

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• 3-Step approachEvaluate, Educate, and Expand

• Programs

• Focus on documentation linked to codes

• Reinforce learning through case studies

• Use de-identified medical records

• Monitor/measure success

Module and Final Exams

Career Step Approach

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Want to Learn More

• White paper on Inpatient Auditing

• Call 1-888-989-7512

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References

• AHA. (October 2016). RACTRAC Survey AHA analysis of survey data collected from 2,580 hospitals: 2,325 reporting activity, 255 reporting no activity through October 2016. 683 hospitals participated this quarter. Data were collected from general medical/surgical acute care hospitals (including critical access hospitals and cancer hospitals), long-term acute care hospitals, inpatient rehabilitation hospitals and inpatient psychiatric hospitals. © American Hospital Association

• http://www.aha.org/content/16/16q3-ractracresults.pdf

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