Top 5 Inpatient Coding Metrics to Pay Attention to During Medical Coding Audits

Medical coding audits are crucial to ensuring accurate and compliant coding practices in healthcare facilities. Monitoring key metrics during these audits helps identify areas of opportunity and assess the overall quality of coding processes. The process can also provide positive feedback and validation to your coding staff. Here are the top five metrics you should pay attention to during your medical coding audits:

Coding Accuracy Rate

• This metric measures the accuracy of codes assigned based on the supporting documentation present in the record at the time of coding. This often includes code additions, deletions and revisions. A high accuracy rate indicates proper coding practices and adherence to applicable guidelines. Conversely, a low rate may indicate an issue with the fundamental understanding and application of coding principles, insufficient documentation, or a variety of other issues. It is also important to analyze cumulative accuracy of diagnosis and PCS codes in order to identify educational opportunities on both an individual and global scale. Occasional errors can be expected, recurring errors represent opportunity. Obtaining the goal of complete and accurate coding means reaching beyond only those codes which impact reimbursement and including those that paint the full picture of patient care.

DRG Accuracy

• In the inpatient coding arena there is no single factor more important to ensuring appropriate reimbursement than DRG assignment. Inappropriate assignments not only lead to ‘at risk’ reimbursement but can also represent a significant compliance risk for the organization. Accuracy is a measurement of whether the assigned DRG corresponds to the patient's diagnosis and treatment. This is often viewed through two lenses: is the DRG change based solely on documentation present in the record at the time of coding, or is it based on a recommended query by the auditor? Keeping the two differentiated can lead to actionable insights for both coding and CDI, ultimately leading to more accurate DRG assignment based on thorough clinical documentation.

Discharge Patient Status Accuracy Rate

• This metric evaluates the accuracy of patient discharge status code assignment. Properly assigning the patient's discharge status is not only crucial for tracking patient outcomes, but it can also impact quality scores and reimbursement.

CC/MCC (Complication or Comorbidity/Major Complication or Comorbidity) Capture Rate

• Monitoring the CC/MCC capture rate during coding audits is crucial for several reasons. Firstly, it ensures accurate reimbursement by appropriately reflecting the severity of illness and resource utilization, which directly impacts DRG assignment. Secondly, it helps identify opportunities for clinical documentation improvement, ensuring that CCs and MCCs are properly documented. Thirdly, analyzing the CC/MCC capture rate provides insights into the complexity of care and resource utilization for quality improvement purposes. It also demonstrates compliance with coding guidelines, reduces audit risks, and allows for benchmarking and performance comparison within the industry. Assessing the CC/MCC capture rate in coding audits is essential for accurate reimbursement, CDI, quality analysis, compliance, and performance evaluation.

Quality reporting (PSI, HAC, 30 day Readmit/Mortality)

• Coding accuracy, or lack thereof, can directly impact quality measures such as Patient Safety Indicators (PSIs), Hospital Acquired Conditions (HACs) and 30-day readmissions/mortality. To ensure that your coding is not having a negative impact on your organization’s quality measures, it is important that you audit any and all records that fall into a measure. Not doing so could result in unwarranted negative performance ratings and, ultimately, reputational and financial damage.

Remember, these metrics are not exhaustive, and the specific metrics may vary depending on the organization's priorities and audit objectives. It's essential to establish a comprehensive audit plan that aligns with your organization's goals and regulatory requirements.

Since 1992, HIA has been the leading provider of compliance audits, coding support services and clinical documentation audit services for hospitals, ambulatory surgery centers, physician groups and other healthcare entities. HIA offers PRN support as well as total outsource support.

The information contained in this coding advice is valid at the time of posting. Viewers are encouraged to research subsequent official guidance in the areas associated with the topic as they can change rapidly.