Who is responsible for coding reconciliation at your facility? Would anyone be willing to share their process? We are trying to streamline our process. Thanks
Each CDS is responsible for reconciliation of their cases. For those cases where the CDS query resulted in DRG impact, we do a second-level peer review to confirm the DRG move to be certain that our financial impact reporting is accurate.
Vivian
Vivian E. Gannon RN,CCM,CCDS Clinical Documentation Improvement Coordinator Chesapeake Regional Medical Center vivian.gannon@chesapeakeregional.com
The CDIS are responsible for reconciliation. Our process until recently:
Coders Code the chart If DRG "mismatch" occurs this prints out on a reconciliation report the CDIS work in their software. CDIS is responsible for commenting as to why the mismatch occurred. There is a section w/in the software to do this. Then we close the acct. If CDIS does not agree w/ coding our process has been to refer the acct. - w/ evidence as to why we think the coding should be reviewed - to the Lead coder for review. If Lead coder agrees she contacts coder w/decision. If she does not or cannot make a decision she refers to coding supervisor. Coding sup. Reviews chart and either makes decision for changes & contacts coder OR if she cannot make decision it goes to outside reviewer (we contract w/an outside source for another software product & she acts as an outside reviewer). The decision from the outside reviewer is usually the standard. Of course we have the right to not take the advice but usually we do not.
At this point we no longer have sup of coding position and our Lead coding position is vacant.
If we do not agree w/the coder we send email and evidence why we do not agree. The coder makes the decision. We can still send to outside reviewer if we do not agree. Also, our RAC Coordinator has been reviewing some cases for us.
Vwery interesting. I wouldlike to know how any of you who use CDIS from 3M might be completing and documenting reconciliation. We have traditionally used email between coders and CDS to communicate and come to a reconciliation, but I'm curious if anyone is using the newly revised 2nd level review expansion in CDIS to document their reconcilation process. Thanks for any insight you can provide. I will respond to the list or separately by email if you choose to contact me off-line.
Sandy Beatty Community Health Ntwork Indpls, IN sbeatty@ecommunity.com
We have DocMS and we are starting June 1st putting all our interactions with coding under the 2nd Lev DRG Review. The goal is to easily track DRG changes. Have not figured out with DocMS (dinosaur program) to monitor SOI/ROM changes. Currently we have used two different spread sheets which required data entry. Hopefully this will cut back on some of the redundancy.
Charlene Thiry RN, BSN, CPC, CCDS Clinical Documentation Specialist Quality Resources Menorah Medical Center
This is where I came from through the years: DocMS and paper, then to CDIS, and now to CDIS as part of 360 Encompass. We use email internally to communicate with coders about mismatches and finally reconcile, but then that communication thread is deleted and we have no record of the discussion. I would like to have that discussion preserved and I envision using the expanded capability for numerous entries in the 2nd level review chapter to do that. I am just trying to jump start the work if any of my colleagues are already doing this and are willing to share their procedures and/or observations.
Sandy Beatty, RN, BSN, CCDS Director of Clinical Documentation Improvement Community Health Network 1500 North Ritter Avenue Indianapolis, IN 46219 317-355-2016 sbeatty@ecommunity.com
Hi Sandy, We are a 360 customer and have been using 3MCDIS for almost 2 yrs now. We will be getting the upgrade with the new 2nd Level Review Chapter next week and plan on using this to document the reconciliation process and discussions with coding. I agree that it is important to have the communication/discussion documented and preserved for future audits/RAC, etc..I don't have a policy yet-waiting to actually walk through the process.
Thanks, Linda
Linda Rhodes RN, BSN, CCDS Manager Clinical Documentation Improvement New Hanover Regional Medical Center Wilmington, North Carolina Office # 910-815-5544 Cell " 910-777-8344 e-mail : linda.rhodes@nhrmc.org
We use a program called eRequest for actual communication which preserves the details with the ability to go back and reference it at any time. We just started in March and I really like it. Our coding staff are off site and following email trails were difficult.
Charlene Thiry RN, BSN, CPC, CCDS Clinical Documentation Specialist Quality Resources Menorah Medical Center
Comments
Vivian
Vivian E. Gannon RN,CCM,CCDS
Clinical Documentation Improvement Coordinator
Chesapeake Regional Medical Center
vivian.gannon@chesapeakeregional.com
How do you do this? Rotating second level review among staff, team lead/manager, are these anonymous (in either direction), etc.?
Are these part of a larger query audit for compliance and quality?
Thanks,
Don
Coders Code the chart
If DRG "mismatch" occurs this prints out on a reconciliation report the CDIS work in their software.
CDIS is responsible for commenting as to why the mismatch occurred. There is a section w/in the software to do this. Then we close the acct.
If CDIS does not agree w/ coding our process has been to refer the acct. - w/ evidence as to why we think the coding should be reviewed - to the Lead coder for review.
If Lead coder agrees she contacts coder w/decision. If she does not or cannot make a decision she refers to coding supervisor.
Coding sup. Reviews chart and either makes decision for changes & contacts coder OR if she cannot make decision it goes to outside reviewer (we contract w/an outside source for another software product & she acts as an outside reviewer).
The decision from the outside reviewer is usually the standard. Of course we have the right to not take the advice but usually we do not.
At this point we no longer have sup of coding position and our Lead coding position is vacant.
If we do not agree w/the coder we send email and evidence why we do not agree. The coder makes the decision. We can still send to outside reviewer if we do not agree. Also, our RAC Coordinator has been reviewing some cases for us.
NBrunson,RHIA,CDIP,CCS,CCDS
Sandy Beatty
Community Health Ntwork
Indpls, IN
sbeatty@ecommunity.com
Charlene Thiry RN, BSN, CPC, CCDS
Clinical Documentation Specialist
Quality Resources
Menorah Medical Center
Sandy Beatty, RN, BSN, CCDS
Director of Clinical Documentation Improvement
Community Health Network
1500 North Ritter Avenue
Indianapolis, IN 46219
317-355-2016
sbeatty@ecommunity.com
We are a 360 customer and have been using 3MCDIS for almost 2 yrs now. We will be getting the upgrade with the new 2nd Level Review Chapter next week and plan on using this to document the reconciliation process and discussions with coding. I agree that it is important to have the communication/discussion documented and preserved for future audits/RAC, etc..I don't have a policy yet-waiting to actually walk through the process.
Thanks,
Linda
Linda Rhodes RN, BSN, CCDS
Manager Clinical Documentation Improvement
New Hanover Regional Medical Center
Wilmington, North Carolina
Office # 910-815-5544
Cell " 910-777-8344
e-mail : linda.rhodes@nhrmc.org
Charlene Thiry RN, BSN, CPC, CCDS
Clinical Documentation Specialist
Quality Resources
Menorah Medical Center
We have 3M HDM with CDIS. We reconcile and document in the 2nd Level
Review tab.