Question: If you notice while reconciling an account that a coder is upcoding, do you discuss the case with the coder first or do you report the incident to his/her director/manager?
Do you have a formal reconciliation process? A policy that details when reconciliation happens, who does it and who is involved? Which accounts? How often?
This should be addressed in your reconciliation policy and procedure.
Do you see a pattern? Have you addressed this problem before?
In the absence of a policy, it is professional to ask the person directly the reasoning behind the coding (the reconciliation of the account should involve communication with the person who coded the account).
It is typically best to work with your peer before moving onto management. This, of course, does not apply in instances of obvious fraud or other egregious activity.
What are you meaning by 'upcoding'? I think intent is very important in issues like this and I have yet to come across a coder who is intentionally 'upcoding'. I certainly come across instances where a coder has (either by accident, assumption, or misunderstanding) added a code that may mean higher reimbursement for the hospital. I hesitate to call this 'upcoding'. For me it depends on how I found this. If the error is found in our regular process where I (or another CDI) am reconciling a DRG after coding or something like that, I go directly to the coder and just let them know that I see that XXX code was applied and I don’t see documentation to support, can they show me where the documentation is or can we change it? But when I see coding errors (positive or negative impact) during retro audits (IE: PEPPER) that are done many months after billing, I generally report these out as a while to our coding manager. When I am done with my audit I send her a copy of the findings so that she can resolve as she sees fit.
Katy Good, RN, BSN, CCDS, CCS Clinical Documentation Program Coordinator AHIMA Approved ICD-10CM/PCS Trainer Flagstaff Medical Center Kathryn.Good@nahealth.com Cell: 928.814.9404
One of (several to many) reasons to strongly consider formal reconciliation processes/policy, auditing processes (specifically queries, but also CDI process), a process for auditing of coding activities, etc.
One digit can be the difference between zero difference in payment versus adding on a CC/ MCC, so I would use caution in calling it "upcoding" unless you really are noticing an issue repeatedly-more likely it is human error: ) We reconcile every single case that has a concurrent review to ensure the most appropriate DRG is assigned. There are times we miss a cc/mcc concurrently (or add a diagnosis that is later ruled out), and likewise there are times the coder may miss or add something that is not present. In these cases, we have a conversation directly with the coder. If the coder has any question about how to proceed, she may have a conversation with our coding supervisor before making changes. When appropriate, the account is rebilled. In the event that you notice a bigger issue than described above, you should not hesitate to bring it to your manager for discussion.
Kerry Seekircher, RN, BS, CCDS, CDIP Clinical Documentation Specialist Supervisor Northern Westchester Hospital 400 East Main Street Mount Kisco, NY 10549 Email: kseekircher@nwhc.net Phone: 914-666-1243 Fax: 914-666-1013
As Kerry indicated, we reconcile every case which has had a CDI review. If we find that we have disagreed with the coders, we have an electronic format to submit a request for reconsideration. At times, they may miss a CC/MCC buried deep in the medical record. There are times, with our volume of new admits and only 5 CDI nurses that we do not return to a case for a second review. This electronic format allows the coding supervisors to trend specific coders to review for possible educational opportunities.
This collaborative effort with the CDI team and the coders has provided a great resource for checking and double checking for accuracy in coding.
It looks like the general concensus is to talk it over with the coder involved first then go to the director/manager if not resolved on that level. Thank you so much.
Comments
This should be addressed in your reconciliation policy and procedure.
Do you see a pattern? Have you addressed this problem before?
In the absence of a policy, it is professional to ask the person directly the reasoning behind the coding (the reconciliation of the account should involve communication with the person who coded the account).
It is typically best to work with your peer before moving onto management. This, of course, does not apply in instances of obvious fraud or other egregious activity.
Hope this helps,
Mark Dominesey
For me it depends on how I found this. If the error is found in our regular process where I (or another CDI) am reconciling a DRG after coding or something like that, I go directly to the coder and just let them know that I see that XXX code was applied and I don’t see documentation to support, can they show me where the documentation is or can we change it? But when I see coding errors (positive or negative impact) during retro audits (IE: PEPPER) that are done many months after billing, I generally report these out as a while to our coding manager. When I am done with my audit I send her a copy of the findings so that she can resolve as she sees fit.
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404
One of (several to many) reasons to strongly consider formal reconciliation processes/policy, auditing processes (specifically queries, but also CDI process), a process for auditing of coding activities, etc.
Don
Thanks for all the input.
Francisca~
We reconcile every single case that has a concurrent review to ensure the most appropriate DRG is assigned. There are times we miss a cc/mcc concurrently (or add a diagnosis that is later ruled out), and likewise there are times the coder may miss or add something that is not present. In these cases, we have a conversation directly with the coder. If the coder has any question about how to proceed, she may have a conversation with our coding supervisor before making changes. When appropriate, the account is rebilled.
In the event that you notice a bigger issue than described above, you should not hesitate to bring it to your manager for discussion.
Kerry Seekircher, RN, BS, CCDS, CDIP
Clinical Documentation Specialist Supervisor
Northern Westchester Hospital
400 East Main Street
Mount Kisco, NY 10549
Email: kseekircher@nwhc.net
Phone: 914-666-1243
Fax: 914-666-1013
This collaborative effort with the CDI team and the coders has provided a great resource for checking and double checking for accuracy in coding.
Thank you
Lisa
Lisa Romanello, RN,BSN,FNS,CCDS
CDI Manager
Thank you so much.