The increased need for accurate coded data for healthcare delivery, reimbursement, compliance, and regulatory accountability has brought about a corresponding need for data quality monitoring and regular evaluation programs. Maintaining data quality is an ongoing effort that affects many aspects of the healthcare environment but relies primarily on the commitment and expertise of HIM professionals.
When implementing a data quality monitoring program, HIM professionals must define the program’s goals and detail how the program will be maintained.
The Importance of Coded Data
Facilities use coded data to monitor performance improvement efforts and make process changes to improve outcomes. Externally, coded data are used for reimbursement, to benchmark data among facilities, and inform consumers of the hospital’s performance.
The need for accurate and complete information has resulted in the necessity for HIM departments to implement a coding audit process to continually evaluate their coders’ level of coding quality. Quality coded data ensure that the coding function is performed at the highest level of accuracy and efficiency possible.
Ensuring ongoing quality is complex because of internal and external factors that affect ICD-9-CM and CPT/HCPCS (and soon ICD-10-CM/PCS) code assignment. These factors include:
- Payers and reimbursement
- Hospital and physician profiling
- Medical record documentation
Payers may require the use of different groupers, which may result in a higher reimbursement or case weight than the same sequencing or code assignment in another grouper. There may also be differences by payer on claims rejected because of selected code assignment.
Physicians may be reluctant to document conditions or situations related to the patients they treat that may have an adverse effect on hospital or physician profiling. Failure to capture diagnoses such as postoperative infections or hemorrhages may compromise these profiles by diluting the complexity of cases.
Medical record documentation factors that affect code assignment are the level of specificity found in the record, whether the documentation is that of a physician and whether the complete record is available at the time of coding. With the implementation of ICD-10-CM/PCS on October 1, 2013, it is imperative that the documentation provide even more specificity in many cases for proper code assignment.
Developing a Quality Improvement Program
The HIM department must begin the development of a data quality improvement program by setting goals. These goals should include the following:
- Establish an ongoing monitor for identifying problems or developing opportunities to improve the quality of coded data
- Proactively identify variations in coding practices among staff members
- Determine the cause and scope of identified problems
- Set priorities for resolving identified problems
- Implement mechanisms, including educational initiatives, to address and resolve the issues identified
- Ensure that corrective action is taken by following up on problems with appropriate monitors
- Implement a program that not only achieves compliance with federal and other mandates but also meets the needs of the organization
The goals and approach to managing and monitoring data quality specifically related to coding must be defined in the department’s coding compliance policy.
Monitoring and Evaluating the Program
The methods to be used for monitoring and evaluation should be clarified within the data quality improvement program. Both internal and external data are important for performance evaluation.
Some areas that should not be overlooked in the coding quality review process are the Office of Inspector General’s work plan focus areas, quality improvement organizations/Hospital Payment Monitoring Program, Recovery Audit Contractor target areas, accuracy of present on admission assignment, complications and comorbidities and major complications and comorbidities, and MS-DRG and APC assignment.
Once the data quality evaluation is complete, coding managers should share the findings from their reviews by:
- Discussing the specific findings from each evaluation and reviewing them with the coding staff
- Discussing the findings with the organization’s compliance officer
- Incorporating specific findings pertinent to individual coders into his or her employee performance evaluations
- Incorporating documentation-specific findings in the organization’s documentation improvement program efforts
- Submitting overall findings to the quality improvement committee for further study
The HIM department should schedule data quality reviews on a regular and ongoing basis. A 2007 AHIMA survey on coding quality measurement indicated that coding quality reviews were most often conducted quarterly or monthly.1
The review schedule often depends on the number of coders and the identified coding problems. If the coding staff consists of several clinical coding specialists, a rotating schedule should be established to review all coders on an annual basis.
For smaller facilities with fewer coding staff, and perhaps without a coding supervisor, the reviews can be conducted by coders reviewing each other’s work, the HIM department manager reviewing the coders’ work, or contracting an external consulting firm to conduct the review.
HIM Manager Responsibilities
The managers play a key role in the data quality review process. He or she is responsible for:
- Preparing specific coding guidelines pertinent to the organization
- Developing action plans to address coding deficiencies
- Planning educational sessions for coders
- Evaluating and monitoring the corrective coding action plans for individual coders
- Monitoring ethical coding practices
- Evaluating and monitoring coding and abstracting quality
- Developing action plans to resolve abstracting deficiencies
- Preparing performance evaluations
Reporting and Trending Coding Errors
Regardless of how or by whom the coding reviews are conducted, the results should be reported and trended. The trending analysis will provide documentation on the progress being made by the coding team in rectifying coding errors. It also will demonstrate the benefit gained from educational opportunities used to enhance coder performance. Trending results will identify those areas that still require attention, which will be followed up on in future reviews.
Melanie Endicott (email@example.com) is a professional practice director at AHIMA.
Endicott, Melanie. “Developing a Coding Quality Improvement Program.” Journal of AHIMA 83, no.3 (March 2012): 54-55.