Third coding audit completed, hospital managers praised
The third in a series of five medical record coding audits required by the Office of the Inspector General (OIG) as part of the MUSC Hospital Institutional Compliance Agreement (ICA) was recently completed.The audit, conducted by Ernst and Young, reported an error rate of only 0.2 percent. All medical records reviewed were appropriately coded with only minor discrepancies. These results were then sent to the OIG.
The auditors praised hospital managers, Christine Lewis and Kelly Shaw, and the Health Information Services (HIS) coding staff.
Reece Smith, chief compliance officer for the hospital, stated that the OIG allows a coding error rate of 5 percent or less. This is the third year in a row that the HIS staff has done an exemplary job, with an error rate of less than 2 percent.
Members
of the coding staff.
This year’s audit was heavily focused on general psychiatric, gastrointestinal and cardiac disorders.
The OIG determines what diagnostic codes will be reviewed based on hospital data and Medicare statistics. MUSC’s highest volume DRG for federal payers is the psychiatric diagnosis of general psychoses. A print out of medical records that listed the five DRGs for review was sent to Ernst and Young. They then randomly selected the medical records to be copied and reviewed.
Susan Pletcher, director, Health Information and Patient Access Services, met with the auditors after the review.
“The auditors closely scrutinized every record, code and patient bill. They read those records from admission to discharge to ensure that all codes and charges were justified,” Pletcher said.
“This type of review is very labor intensive and stressful,” Pletcher
added. It requires a team effort by all HIS employees, from those who assemble
the records, to those who must retrieve the records requested from the
warehouse. Managers, reviewers, the Compliance Office and Hospital Patient
Accounting are also involved. Everyone should be commended.
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