We use the code-over-code approach recommended by the American Health Information Management Association (AHIMA) publication Benchmarking to Improve Coding Accuracy and Productivity published in 2009.
The code-over-code approach uses the reviewer’s codes as the denominator and the coder’s correct codes as the numerator. There are times when the coder’s correct codes may be 0 and, of course, that will lead to a 0 percent accuracy rating.
Additionally, if the reviewer deducts for codes that the coder should not have assigned, the net number of correct codes assigned by the coder could be a negative. For example, if the coder assigned two symptom codes and one definitive diagnosis code that those symptom codes supported, then the coder had one correct minus two incorrect codes or a negative one.
Although it’s an option, First Class Solutions stopped using a negative numerator. Instead, we use these situations as education moments.
Code-over-code can be used to assess accuracy of present on admission (POA), any subset of codes such as social determinants or health (SDOHs), and other items such as abstracted data elements.
Another approach that’s easier to use and requires less counting is the case-over-case approach that is often used to determine if the correct DRG or APC was attained.
For the DRG or when there is one APC, it’s either a yeah or nay. If there are multiple APCs, then the code-over-code approach can be used.
Case-over-case is also known as the financial accuracy rate when it is used to reflect DRG or APC accuracy. But, we all know you can get the right DRG but not use the most specific code. So, the DRG is right, but the code is wrong.
Bottomline, use code-over-code for coding accuracy and use case-over-case for financial accuracy. If you use case-over-case for coding accuracy, it’s harsh, and doesn’t give the coders credit for their correct codes.
No doubt you’re aware that some coding lives in the grey area. That is, there are some codes that are clearly correct, some that are obviously wrong, but some which are up to the interpretation of the coder.
How does an auditor handle that?
Coding professionals recognize that coders and reviewers may find documentation to support their codes in different and legitimate places. When a coder doesn’t agree with the reviewer, that’s the purpose of the rebuttal phase in any coding review.
One of those situations that’s up to the interpretation of the coder is the option in the Guidelines to choose between two conditions that clearly support the reason for admission and sequence one over the other as the principal. However, most organizations choose the diagnosis that is financially beneficial but that’s not a requirement and we know payers often deny and flip the diagnoses to their advantage.
The driver when we get into situations where there may be some “grey” is to revisit the documentation to see what is truly supported and then follow the hierarchy of “coding rules.”
- First, the Coding Conventions
- Second, the Coding Guidelines
- Third, the Coding Clinic.
To paraphrase a quote from the Godfather, take it to the Index and tabular.
Don’t assume your encoder took you down the right path. Go to the book index and tabular and if that comes up with something that doesn’t seem right, go to the Guidelines and the Coding Clinic.
If the documentation is unclear or questionable, take it to the physician with a query.
Finally, if the hierarchy of coding rules map to a diagnosis that just doesn’t tie with the documentation, then there’s the option to petition for a code from the Coordination & Maintenance Committee, which may lead to a Coding Clinic.