Coding Overview and the DQ Manager

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Why Worry About Data Quality?. I turned in my Data Quality Statement. Aren\'t I accomplished for the month??. I presented my Data Quality Statement for the month. Aren\'t I done??. Why Worry About Data Quality?. . Inside and External Scrutiny. It Takes a Team. You are the guardian checking the information flowIt takes a group to be successfulDQ Manager, Resource Management Office (RMO), Group Practice Man

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Coding Overview and the DQ Manager DQMC February 2009

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Why Worry About Data Quality? I presented my Data Quality Statement for the month. Aren't I done?? I handed over my Data Quality Statement. Aren't I accomplished for the month??

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Why Worry About Data Quality? Inward and External Scrutiny

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It Takes a Team You are the guardian observing the information stream It takes a group to be effective DQ Manager, Resource Management Office (RMO), Group Practice Manager (GPM), MEPRS Manager, Credentials Manager, Budget Analyst/Uniform Business Office (UBO), Coding/Billing Supervisor, Clinical Systems Administrator(s) Are procedures set up to guarantee information honesty? Are supplier documents set up effectively? Is your MTF getting the workload they earned?

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First Priority Make it a Partnership - Providers and Coders AHLTA preparing – Providers, AHLTA mentor AND Coder/Auditor Use of layouts to streamline documentation Feedback and preparing to supplier – YOU NEED TO CLOSE THE LOOP! We are in this together - convey Curren t coding assets should be accessible for center, supplier and coder/examiner utilize

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Second Priority Ensure there is a procedure set up to distinguish AND to review all billables! Run answer to distinguish experiences CCE worklist OR Run Preview List in CHCS Perform review of coding Correct blunders Query supplier if documentation is misty Don't release a bill out the entryway without a review!

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Reports Relating to Coding ADM Write-Back Error Report Look at blunder sorts Correct the ones you can Monitor the ones redressed at corporate No ADM Kept arrangements that have not been coded Missing SADRs SIDR Transmission Make beyond any doubt you get acknowledgment for the work you've done!

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Relative Value Units The money of the MHS Measured at all levels, including singular supplier level Used for benchmarking

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RVUs Are an approach to contrast assets utilized with create an item Examples of items are: Office visits Excision of a sore Delivering a child

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Birth of a RVU RVUs are Professional and Practice Expenses related with a CPT Provider-tolerant communication (typically) Documented Coded with a Current Procedural Terminology (CPT) Evaluation and Management (E&M) Surgical Procedure Other Procedure Healthcare Common Procedural Coding System (HCPCS) Not every single, numerous ar sturdy hardware or supplies Look up the code in the RVU table

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What do the parts resemble? "Work" "Hone Expense" "Negligence"

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RVU Example CPT 11100 - Skin biopsy

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Is this Correct? On the off chance that an attendant is the main person who communicates with the patient on the phone, is it a legitimate therapeutic record if the specialist signs it and assumes praise for it? In the event that an expert is the just a single required with patient care, is it a lawful medicinal record if the doc signs it and assumes acknowledgment for it? Try not to bargain your respectability or confer misrepresentation for Relative Value Units.

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2004 UBU-UBO Conference ED Example Patient found in Emergency Department (ED) subsequent to getting in a battle with a Thanksgiving Turkey ED specialist archives ER visit to incorporate 4 fastens in palm of left hand and lockjaw shot Coded with 99282-25, 12002-LT, 90703, 90471

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ED Example

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Relative Value Units Are Only Part of What You Do Lots of what you do is not "codable" Hall way counsels Effectiveness reports/non military personnel examinations Extra time spent comforting a deprived patient Shoveling snow/grabbing trash after tropical storms/tornados Discussing an AD with psychological well-being condition with his/her Commander Participating on MEBs Reviewing and returning counsels for more data Reviewing outlines just to have the patient no show Waivers/PHA/pre-and post organization briefs Quality confirmation (over perusing EKGs) Preparing and giving talks at amazing rounds Medical inprocessing Overseas clearances ADAPT

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Workload Capture Impact of Provider Specialty Code (PSC) Proper HIPAA Taxonomy Code ought to be connected to remedy PSC 910 or more are Clinical Services Do not utilize Default PSC 000 (DMO) Codes 500 – 518 and 910 – 999 Bottom line – lost or mistaken PSC = 0 workload!

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Putting the Puzzle Together

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Value of Care PEDIATRICS – BDA Provider Specialty Code = 040 Pediatrician Diagnosis Codes 204 Lymphoid Leukemia 112.89 Candidial Endocarditis Procedure Code 90780 Intravenous implantation for treatment/conclusion, managed by doctor or under direct supervision of doctor; up to one hour 90781 – Each extra hour E&M Code 99214 – Level 4 Established Patient OHI – Yes CMAC Value = $130.73 Class 1 Provider Will you charge for this patient? Yes Reimbursement - $130.73 PPS RVU = 1.44 Reimbursement = $106.56 PEDIATRICS – BDA Provider Specialty Code = 949 Pediatrics Diagnosis Codes 204 Lymphoid Leukemia 112.89 Candidial Endocarditis Procedure Code 90780 Intravenous implantation for treatment/finding, controlled by doctor or under direct supervision of doctor; up to one hour 90781 – Each extra hour E&M Code 99214 – Level 4 Established Patient OHI – Yes CMAC Value = UNKNOWN Will you charge for this patient? NO Reimbursement $0 PPS Workload = ZERO!!!!!!

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Provider File Issues Provider Naming Conventions Provider ID NPI – invalid or copy = NO $$$ Provider Class PSC and HIPAA Taxonomy External Providers SSN not obligatory Need either DEA# of License #

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Provider File Standards and Business Rules - Example

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Other Provider File Issues External Providers – including new suppliers for Ancillary Services Internal Providers - Incoming Credentials pulls information from CCQAS and checks qualifications Build profile in CHCS Providers – Outgoing Inactivate Provider from Patient and Appointment System (PAS) profile(s) and the Managed Care Program (MCP) Provider Group(s) as required Order Entry Inactivation Date in which the supplier can no longer acknowledge New requests This does not avert existing requests to process Termination Date in which the supplier stopped to be utilized by the MTF Terminate – following 1 year

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Corrected fields in red : PROVIDER: SMITH,JOHN R Name: SMITH,JOHN R Provider Flag: Provider ID: SMITHJR NPI Type/ID: 01/0125899 Provider Class: OUTSIDE PROVIDER Person Identifier: Person ID Type Code: Select PROVIDER SPECIALTY: 001 (FAMILY PRACTICE PHYSICIAN) Primary Provider Taxonomy: 207Q00000X CMAC Provider Class: - Select PROVIDER TAXONOMY: HCP SIDR-ID: Location: CHAMPUS SUPPORT Class: OUTSIDE PROVIDER Initials: JRS SSN: 123-45-6789 (Not Mandatory) DEA#: BM1212127 License #: Incorrect fields in red : PROVIDER: SMITH, JOHN R Name: SMITH, JOHN R Provider Flag: Provider ID: Provider1234 NPI Type/ID: Provider Class: Doc Person Identifier: 123-45-6789 Person ID Type Code: Select PROVIDER SPECIALTY: 517 (DENTAL CONSULTANT) Primary Provider Taxonomy: CMAC Provider Class: - Select PROVIDER TAXONOMY: HCP SIDR-ID: Location: CHAMPUS SUPPORT Class: OUTSIDE PROVIDER Initials: JRS SSN: 123-45-6789 DEA#: 99999999 License #:

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Final Word - Medical Necessity "Outpatient Admissions" don't exist Admit just if there is therapeutic need Not to "give nursing credit" when an Ambulatory Procedure Visit persistent stays after the Ambulatory Procedure Unit closes for the night Patient staying past midnight is not a programmed confirmation Patient in perception over 24 hours is not a programmed affirmation

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Take Away Data Quality is not quite recently the DQ articulation. Information should be precise, opportune and finish. Cleaning the front end will demonstrate an arrival toward the back.

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Questions??

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