CLINICAL CODING AND CASEMIX AUDIT Essay Example

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17CLINICAL CODING AND CASEMIX AUDIT

CLINICAL CODING AND CASEMIX AUDIT

Executive Summary

In the clinical profession, auditing provides an important check for ensuring that the safety and the quality of patient care and contributing the vast research in medicine enhancing the delivery of evidence-based health care. The production of accurate clinical documentation that is consistent and transparent about a patient who has been cared for is a fundamental role of the clinician’s profession. As a Manager for Clinical Coding and Casemix, I am tasked to undertake a formal internal clinical coding and case mix proposal for audit to be presented to the Chief Executive Officer (CEO)

The history of clinical coding and case mix audit encompasses the Activity Based Funding and Management (ABF /ABM) that was designed in the year 2010, which presents an innovative way of managing the health care industry. Consequently, ABF/ABM ensures that there a consistent flow of health resources and services to the regions whereby the resources are most required. The Activity Based Funding and Management (ABF/ABM) organization requires highly accurate and timely information about patients who visit healthcare providers and the un-ending support for high quality and safe healthcare to the society.

The audit information will be used by doctors, clinicians, the community, the government and public servants in their quest to design informed decision in matters that affect the health care of the community across the whole nation. The team work spirit within the clinical profession will help everyone to deliver excellent healthcare services, and this report discusses the aspects of Clinical Coding and Casemix Audit documentation and plan that will assist all the stakeholders to make informed choices in their work.

Table of Contents

Executive Summary 2

Clinical Coding and Casemix Audit 4

Introduction 4

Rationale 5

Methodology 6

Literature Review 7

Benefits of Clinical Casemix and Coding 7

Clinical Coding and Casemix Audit Elements 12

Timeframe 12

Purpose and Scope of the Audit 12

Audit Team 13

Audit Tools 13

Presentation of the Audit Findings to the CEO 14

Conclusion and Recommendations 14

References 16

Clinical Coding and Casemix Audit

Introduction

The quality and accuracy audit information in any healthcare medical center is a key element in the quality and safety of the healthcare provided. It is also an indication that the healthcare provider is compliant with the regulations within the sector, and quality healthcare is given within the institution. In this report, the documentation of the audit plan and procedures, and the benefits of Clinical Coding and Casemix Audit will be highlighted. The Clinical Coding and Casemix Audits are used to classify, collect, code, cost and count the wide range of healthcare products that are provided by hospitals. This facilitates for the effective and efficient healthcare that is required to provide high safety and high-quality healthcare. (Alison, 2015)

In this case, it is important for health care management and clinicians to note the following points;

  • The Clinical Coding and Casemix Audit affects the manner in which healthcare services are delivered and the workforce involved in it. This stipulates the future plans for healthcare services based on the audit information about the current trends of healthcare needs.

  • The Clinical Coding and Casemix Audit impacts the funding of healthcare services

In this report, the clinical coding process will be outlined, and the focus will be on the benefits of Clinical Coding and Casemix or Diagnostic Related Groups (DRGs) Audits. From the utilization of Clinical Coding and Casemix Audit diagnoses and co-morbidities or complication, they determine the complexity levels and care mechanisms. In the report, most of the key components of Clinical Coding and Casemix Audit process will be outlined highlighting the importance of documenting the clinical information accurately for the patients’ medical records as shown in the documentation process in Figure 1.

Name of Student

Figure 1: The Process Of Documentation From The Patient Admission To The Final Data

Rationale

The key aspect of Clinical Coding and Casemix Audits is to examine carefully the inpatient data, focusing on the accuracy of ICD-10 codes and the AR-DRG assignments. The audits select the episodes of patients randomly to review the discharge summaries and medical data.

Clinical Coding and Casemix Audits usually allow the management to draw some policies on how to precisely document the procedures and diagnoses to ensure that the healthcare provider is effectively reimbursed for the treatment of the patients within the hospital.

The audits conducted present an opportunity to improve the communication between the clinical coders, clinicians, and the management by highlighting any possible errors or anomalies in the ICD-10-AM code classification. The anomalies are reported to the relevant stakeholders such as clinical and health care management, the Government or Commonwealth organizations in a bid to facilitate the review of procedures to be amended for future versions of the coding classification. The coding is usually conducted by a team of Finance, and business Modeling accredited auditors. (Goldin, 1991)

Methodology

The main aim of the Clinical Coding and Casemix Audit is to enhance the accuracy of coded patients’ data and represent the information for the purpose of;

  • Providing a greater understanding on the scope by outlining the benefits of clinical coding of disease processes, clinical practice and intervention techniques within the hospital

  • Enhancing the management’s understanding of the hospital’s case mix as well as the activity based profile.

  • Providing a better understanding of the clinical codes and procedures of healthcare information to the CEO and healthcare managers and the factors that influence the representation of accurate data within the hospital.

  • Providing enhanced understanding for clinicians on what is expected regarding patient notes, summaries of discharge in a bid to comprehensively present the coding of a patients visit.

Literature Review

Benefits of Clinical Casemix and Coding

Casemix usually refers to the mix of cases or many types of patients that are treated by the healthcare provider or hospital. This usually gives a comparison between the levels of the hospital and other related services, mainly contributing to the management and overall planning of the health care system. This is done by putting the patients into clinically meaningful classifications. (Dart, 2009) Consequently, the output is the clinical cost efficiency, effective activities, quality and safety of the various diverse healthcare providers and hospitals is compared.

Casemix data is used for many purposes that include;

  • Financial management and funding

  • Clinical scientific research

  • Identification of epidemiological patterns and trends of diseases and ailments

  • Workforce and resource planning

  • Comparing between healthcare facilities in the community, regions or states

  • Gauging the quality of health care delivery

  • Revision of resource consumption

Clinical coding constitutes the extraction and review of information for the medical data and records that are based on the documented information of clinical records, thus translating the data and information into clinical code. The information varies from;

  • primary diagnoses

  • principal diagnoses

  • Complications

  • Diagnostic or therapeutic procedures

  • Co-morbidities that are admission-relevant

Through the accurate audit code and documentation, the coder will be able to translate the information into a series of numerical and alphanumerical coding patterns that represent the whole clinical procedure as depicted in the Clinical Coding Structure Figure 2. For instance, the International Statistical Classification of Diseases and Related Health Issues ICD-10-AM that is used by clinical coders as shown in Figure 3. This is the 10th revision in the Australian Modification of 1st July 2010, 7th Edition. (Goldin & Olivetti, 2013)

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Figure 2: Clinical Coding Structure

The ICD-10-AM is composed of;

  • The Australian Classification of Health Interventions, ACHI that is an Australian classification based on Medicare Benefits Schedule, MBS

  • A set of policies that are aiming to standardize the clinical coding practice in the Australian region, in which the specific issues and general principles issues are covered. This is the ACS or Australian Coding Standards

  • The WHO disease classification code classified on ICD-10 with revisions to improve on the current classification for the clinical procedures within Australia.

Name of Student 2

Figure 2: The Typical ICD-10-AM Classification Procedure

As described in Table 1, the complexity of health care usually captured through clinical coding, is refunded at a higher rate that amounts to higher costs or expenses that are incurred within the administration of the health care service. (Gilbert, 2012) Essentially, the benefit is that the complexity is captured within the medical records by documenting the diagnoses, co-morbidities and complications.

Name of Student 3

Table 1: A Typical Example of DRG Inflammation or Infection of the Joint with Musculoskeletal Miscellaneous Clinical Procedure

Another key benefit of the coding procedure is to estimate the costs of providing the healthcare to inpatient conditions who overstay and exceed the payment or reimbursement of the healthcare provider or hospital as depicted by the red line. As seen in Figure 4, the model of average cost per episode depicted by the green line represents the link that exists between the time spent by a patient’s stay within the hospital and the expenses of the healthcare service. Clinical management can take use of this cost modeling for in-patients to ensure that there are checks in the reduction of hospital stay by improving efficiency and design incentives for early discharge whereby it is appropriate.

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Figure 4: Model of Inpatient Cost

Clinical Coding and Casemix Audit Elements

Timeframe

The audit timeframe will take up a period of 2 months with all the audit documentation approved and signed off by the relevant audit teams. The audit scope will include;

  • Quality division performance activity audits — 3 weeks

  • Random selection of patients’ episodes for audit — 2 weeks

  • Raising of potential errors and anomalies in the discharge summaries and classification weights — 2 weeks

  • Documentation of audit information — 1 week

Purpose and Scope of the Audit

As discussed in the previous section, the main purpose of the audit program is the examination of inpatient data with a keen emphasis on the accuracy of the ICD-10 code classification. These enhance the communication between the clinical management, clinical coders, and clinicians. Any anomalies are reported in a bid to allow for consideration for revision by the relevant Governmental and Commonwealth organizations for future versions of the clinical classification. (Goldin & Olivetti, 2013) Essentially, quite some guidelines are designed to ensure that the procedures and diagnose at the health care provider or hospital are efficiently reimbursed for the treatment of patients.

Essentially, The accuracy of coded patients’ data and represent the information for the purpose of providing a greater understanding on the scope by outlining the benefits of clinical coding of disease processes, clinical practice and intervention techniques within the hospital. Moreover, enhancing the management’s understanding of the hospital’s case mix as well as the activity based profile. Also, providing a better understanding of the clinical codes and procedures of healthcare information to the CEO and healthcare managers and the factors that influence the representation of accurate data within the hospital. Finally, providing enhanced understanding for clinicians on what is expected regarding patient notes, summaries of discharge in a bid to comprehensively present the coding of a patients visit.

Audit Team

The audit team consists of;

  • Clinical coders

  • Clinicians

  • Health Information Management

  • Accredited Audit team from Finance and Business Modeling Directorate

  • Classification or Grouper Software System Users

Audit Tools

Some state of the art technological software tools will be used to analyze the data. This includes questionnaire links, Performance Management Tools, Shared Rating Tools, Classification or Grouper Software System and Documentation tools. The choice of the tools is depicted by the need for accurate clinical data and information for modeling purposes. Regression tests are conducted on the ICD-10 coding to ensure that randomly selected data is reviewed through the summary of discharges and patients’ medical information. (Greenwood, et al., 2008)

Presentation of the Audit Findings to the CEO

Most of the finding will be summarized as charts and graphs and presented to the CEO, highlighting the most important points for the Clinical Coding and Casemix Audit. The Findings from the Audit will focus on the Clinical Coding and Casemix Models for the presentation to management. This is because the management has limited time to go through all the finer details of the findings, it is important to highlight the anomalies and assumptions made throughout the audit, for accuracy purposes

Conclusion and Recommendations

In all clinical audit documentation on Clinical Coding and Casemix, the data should comply to the health services policies of the local requirements. However, it is critical to ensure that;

  • Daily healthcare plans are documented

  • Relevant audit documentation is completed

  • Summaries of discharge are completed at the event of discharge.

To be clinically relevant with the Clinical Coding and Casemix Audit procedures, the health care provider should ensure the following records on patients are retained and up-to-date;

  • Examination patients’ records

  • Diagnosis patients’ records

  • Management patients’ records

  • Anesthetic patients’ records

  • Progress notes patients’ records

  • Emergency and Outpatient records

  • History of the patients’ personal and family

References

Alison, Howard J. «Clinical Classification Codes», ISBN No. 978-1-922096-87-6. (2015): 7-19

Dart, Robert A. «The Role of Clinical Coding and Casemix Audit» IZA DP No. 4006. (2009): 1-41

Gilbert, James. “ICD-10-AM Code Classification: Health Care in Australia by Ralph Larissa. Australian Journal of Health Care and Sociology .117:4 (2012): 1282-84

Goldin, Claudia D. HealthCare Data Accuracy. The Australian Sociology Review. 81:4 (1991): 741-56

Goldin, Claudia & Olivetti, Claudia. Healthcare Systems: A Reassessment of the Role of Coding In Clinical Data. National Bureau of Health Care Research Working Paper 18676 (2013): 1-32

Greenwood, Jeremy & Gunner, Nazi. Medical Data: Analyzing the Role of Technological Progress on the Design of Audit Tools. DYER HealthCare Providers Annual. 23:1(2008): 231-76