DCBA

Does Your Hospital Need a Clinical Documentation Audit but Only Got a Coding Audit?

by Robert Gold, MD

Many consultants do coder accuracy audits and leave too much untouched.

Certainly an analysis of the accuracy and effectiveness of your coding staff is important in order to feel secure that your department is … accurate and effective. And at one time, this was all that was actually required. But the times they are a'changin.'

In this era of compliance, of CERTs and RACs and MACs, of profiles, of payment for complexity and severity of illness and of patient safety, the only way that a hospital can survive is to ensure that the coding accurately and specifically reflects what is wrong with the patients. And a directed coding audit cannot accomplish that.

Many hospitals have established a Clinical Documentation Improvement Program with staff, whether coders or nurses, designated to evaluate the notes that a physician puts in the medical record and help the doc better reflect the disease process, to identify the principal diagnosis, to identify comorbidities more precisely and to validate that the patients are truly ill. Hospitals that cannot afford the typical clinical documentation improvement program will take shortcuts to save a nickel here or exclusively perform retrospective queries to save a penny there and they do the best that they can. But the capabilities of any of these models to determine the clinical aspects of the diseases and procedures to which codes are assigned depends on precise clinical evaluation of the diseases that the patients have and then seeing if the physician has written the right words in the charts – and if the physician hasn't, it's important to educate the doc.

Coding audits that merely identify if the codes assigned to any case capture the words written in the chart do not take into account those clinical aspects. They look at "Did the coder assign the accurate and specific code based on what's written, following the rules" rather than "Do the codes assigned tell the story of the illnesses the patient has." And not only the diagnoses! Do the codes assigned really reflect the procedures that the physician actually did or do they reflect what the physician said he did. And you can't do that with a coding audit. Clinical documentation and coding audits are best done with a team of a physician and an expert coder – a physician who knows the coding rules and a coding specialist who understands clinical documentation and the diseases and the procedures.

DCBA's medical record audits are just that – audits of the record of the patient's interaction with the providers of the delivery of that medical care. We analyze the diseases the patient has coming through the door, we analyze those conditions that get worked up and linked or not to the presenting symptoms, we analyze the actual procedures done rather than what the physician called them and we determine if the clinical documentation tells the right story. Then we look at the coding. The coding may reflect what the physician said, of course, but it may have errors that are derived from misinterpretations of the information that the physician provided.

So what's the outcome of such a process? It's the determination of educational needs of physicians or coders or, and this is really where the rubber meets the road, is your clinical documentation improvement program where it needs to be? Are your CDI specialists asking coder questions? Do they have the respect of the medical staff derived from knowledge of the diseases or are they concentrating on lab results regardless of the conditions that patients actually have? Are your questions, whether concurrent or retrospective, meeting the needs of accessing the proper results or are you asking questions that a physician has no chance of answering the way you expect they should?

Your hospital, your medical staff, your coders and your patients deserve such an evaluation. They can't get things better if they don't know what's wrong. And you cannot create a corrective education process if you don't know which part of the entire schema needs corrective education.

Call DCBA, Inc to schedule an evaluation of your coding, of your inpatient billing, of your medical staff's clinical documentation, of your CDI specialists' effects and effectiveness.