“Comprehensive Audit Plan for CC/MCC Capture Rate Analysis at Memorial Hospital”

QUESTION

Categorizing the Components of an Audit Plan.

Review the audit scenario provided below. Place the applicable portions of the scenario into the correct audit plan category by following the prompt in the figure below.

Calvin is the Compliance Director at Memorial Hospital. He has been preparing an audit that was required by the chief financial officer (CFO). The audit results will be presented to the hospital executive committee. The focus of the audit is the CC/MCC capture rate. The coding dashboard includes this metric for the top five MS-DRG families. The capture rate has been decreasing over the past six months. The CFO wants to identify the root cause of the decrease and implement solutions as soon as possible.

Calvin has contracted with Amazing Auditors to conduct the external review. Amazing Auditors is a local firm and will conduct the audit on-site at Memorial Hospital. The auditors will have access to the EHR medical documents, CDI queries and responses, and the UB-04 billing form for each inpatient admission to validate reported secondary diagnoses and to identify unreported secondary diagnoses.

Amazing Auditors will audit 200 records from the past 12 months (June 1, 2022 through May 31, 2023). This will provide information for encounters prior to and during the CC/MCC capture rate decrease.

Calvin is going to use a stratified random sample to identify the admissions for the audit. He is selecting records from no CC/MCC MS-DRGs and from with CC MS-DRGs. Both categories represent MS-DRGs where a higher level of severity could have been missed by the coding unit.

The coding unit has an accuracy rate metric of 92 percent. The compliance rate for the audit will be determined by the code over code method. The audit will take place during the fourth week of March. At the completion of the audit, Amazing Auditors will provide a debrief with representatives from HIM, coding, compliance department, patient financial services, CDI, and the CFO. The written report will be provided within three weeks of the end of the audit.

Who:

1. The audience is:
2. The audit will be conducted by:

What:

1. The focus of the audit is:
2. The documents and data points included in the audit are:

Where:

1. The audit will take place at:

When:

1. The records included in the audit are from:

Why:

1. The facility needs to perform the audit because:

ANSWER

Who

The audience is: The primary audience for this audit is the hospital executive committee, including the chief financial officer (CFO) who initiated the audit. Other key stakeholders include Calvin, the Compliance Director at Memorial Hospital, and the external audit firm, Amazing Auditors.

The audit will be conducted by: The external audit firm, Amazing Auditors, a local firm contracted by Calvin, the Compliance Director, will conduct the audit on-site at Memorial Hospital. They will be responsible for carrying out the audit procedures, data collection, and analysis.

What

The focus of the audit is: The primary focus of this audit is to assess the CC/MCC (Complication or Comorbidity/Major Complication or Comorbidity) capture rate. Specifically, the audit aims to investigate the reasons behind the decreasing capture rate over the past six months. The goal is to identify the root cause of this decline and develop solutions for improvement.

The documents and data points included in the audit are: The audit will encompass a range of documents and data points, including:

EHR (Electronic Health Records) medical documents: These records contain patient information, including diagnoses, treatments, and medical history, which are crucial for evaluating the accuracy of coding.

CDI (Clinical Documentation Improvement) queries and responses: These communications between healthcare professionals provide insight into the clarification and completeness of medical documentation.

UB-04 billing forms: These forms are essential for cross-referencing the reported secondary diagnoses and identifying any unreported secondary diagnoses.

200 records from the past 12 months: This sample of inpatient admission records, covering the period from June 1, 2022, through May 31, 2023, will help assess CC/MCC capture rates before and during the decline.

Stratified random sample: This method of sample selection involves both “no CC/MCC MS-DRGs” and “with CC MS-DRGs,” ensuring that a range of cases is audited, including those with a potential for missed higher-severity diagnoses.

Coding accuracy rate metric: The coding unit’s overall accuracy rate, which is 92 percent, serves as a reference point for evaluating the compliance rate during the audit.

Where

The audit will take place at: The audit will be conducted on-site at Memorial Hospital, where all relevant documents and data are readily accessible. This physical presence ensures that auditors can review records, communicate with hospital staff, and conduct a comprehensive assessment.

When

The records included in the audit are from: The audit will encompass records from the past 12 months, spanning from June 1, 2022, through May 31, 2023. This timeframe allows for an examination of cases both before and during the period when the CC/MCC capture rate has been decreasing. The audit itself is scheduled to take place during the fourth week of March.

Why

The facility needs to perform the audit because: The audit is essential for several reasons. First, the declining CC/MCC capture rate may have financial implications for the hospital, as it affects reimbursement rates and revenue. Second, it is crucial for ensuring the accuracy and completeness of medical coding, which impacts patient care quality and compliance with regulatory requirements. Identifying the root cause of the decline and implementing solutions promptly is necessary to address any issues in coding, documentation, or processes and ultimately maintain the hospital’s financial health and the quality of patient care. Furthermore, the audit is a proactive step in response to the CFO’s directive, demonstrating the hospital’s commitment to transparency, compliance, and continuous improvement in healthcare operations.