CHECKLIST: CQMR – Coding Quality Monitors and Reporting

A.1: Revenue Cycle and Reimbursement
Competency: Apply policies and procedures for the use of data required
in healthcare reimbursement (BL3)
Curricular Considerations: Payment methodologies and systems including capitation,
Prospective Payment System (PPS), Resource Based
Relative Value Scale (RBRVS), case mix, indices,
MSDRGs, healthcare insurance policies, and Accountable
Care Organizations (ACOs)
Subdomain IV.A.2: Revenue Cycle and Reimbursement
Competency: Evaluate the revenue cycle management processes (BL5)
Curricular Considerations: Billing processes and procedures (claims, Explanation of Benefits (EOB), Advanced Beneficiary Notice (ABN), Electronic Data Interchange (EDI), coding, Chargemaster, and bill reconciliation process) in hospital inpatient, outpatient, physician offices, and other delivery settings;
Utilization review and case management/care coordination
Domain V: Compliance
Subdomain V.A.3: Regulatory
Competency: Adhere to the legal and regulatory requirements related to health information management (BL3)
Curricular Considerations: Legislative and regulatory processes (coding quality monitoring, compliance strategies, and reporting)
Subdomain V.C.1: Fraud Surveillance
Competency: Identify potential abuse or fraudulent trends through data analysis (BL3)
Curricular Considerations: False Claims Act (Stark Law, Anti-Kickback Statute, and Whistleblower Protection Act); Role of Office of Inspector General (OIG) and Recovery Audit Contractors (RACs), Unbundling and upcoding (Fraud/Abuse)
Subdomain V.D.2: Clinical Documentation Improvement
Competency: Develop appropriate physician queries to resolve data and coding discrepancies (BL6)
Curricular Considerations: Clinical Documentation Improvement (CDI); Professional Communication Skills; Roles of physicians and HIM in CDI
Domain VI: Leadership
Subdomain VI.H.1: Ethics
Competency: Comply with ethical standards of practice (BL5)
Curricular Considerations: Professional and practice-related ethical issues; AHIMA Code of Ethics
Upon successful completion of this course, students must be able to:
Assess the importance of coding quality to facility reimbursement (BL5)
Assess the importance of reimbursement monitoring and reporting for the viability of the healthcare facility (BL5)
Determine the need for reporting findings on coding quality for ongoing clinical documentation improvement (BL5)
Investigate revenue cycle monitors to identify trends (BL4)
Identify potential abuse or fraudulent cases of Monthly/Quarterly Write-offs and weekly rejections (BL3)
Identify the major laws supporting prosecution of fraud and abuse in healthcare and the roles of various agencies in prosecuting these cases (BL3)
Discuss the role of the Health Information professional to coding quality and documentation (BL6)
Explain the importance of documentation to quality of patient care and facility reimbursement (BL2)
Justify the importance of the application of the AHIMA Code of Ethics to facility reimbursement and revenue processes (BL5)
Tasks: You have been the supervisor of coding for about 6 months at a local community hospital. You have been familiarizing yourself with what has been happening in the areas of quality, quantity, work ethic and compliance with all coding regulations and requirements.
Every week you receive a list of rejections that you need to review and provide recommendations to appeal if needed. The priority are high volume and high $ amount rejections. You recognize that there is a problem with the quality of the coding related to:
1) Medical necessity;
2) Medicare reimbursement policy regarding assistant surgeon;
3) Reimbursement policy of commercial plan regarding age of patient;
4) Missing or incomplete documentation.
Please see table – summary of rejection issue, findings and recommendations. Use Encoder Pro software to identify the correct CPT procedure codes and ICD-10-CM diagnosis codes; determine the LCD policy of CPT 93880 and identify the list of diagnoses supporting medical necessity; use Encoder Pro NCCI edits for multiple procedures and apply the correct modifiers to bypassed the edits; print the result of Physician Compliance Edit.
The coding review you performed showed the coding quality significantly below the established benchmark of 98% accuracy. Evaluate your findings and create a report. This report must be typed in Times New Roman, size 12 font and be 2-3 pages in length and double-spaced. It should also contain a cover page with a title of your report that can be used to identify what the report contains, your name and date of the report. This report should be attached to this document upon completion.
1)Perform steps to determine the problems involved and enumerate the recommendations for each rejection issue; Part of each recommendation is to query physician and/or educate physician. For documentation issue, design and complete the documentation requirements of Progress Note and indicate documentation supporting procedure and diagnosis.
2) Develop necessary procedures/policy for coding quality, documentation compliance and compliance with insurance reimbursement policy.
3) Determine the importance of coding quality and accuracy through ongoing monitoring and reporting.
4) Evaluate the significance of implementing coding quality processes for healthcare facilities.
5) Investigate potential fraud and abuse with these rejections.
6) Justify the application of the AHIMA Code of Ethics.
7) Describe the role of the Health Information professional to coding quality, compliance, and reporting.
8) Describe the role of the provider to clinical documentation improvement.
9) Relate the importance of computer assisted coding (Encoder Pro) to coding quality and facility reimbursement.
Standards: Students must achieve a minimum score of 70%.

Evaluate rejection issues, complete the findings and recommendations ____/20
Relate coding quality to reimbursement and compliance ____/10
Assess the interrelationship between accurate coding and physician
documentation ____/10
Describe purpose and function of coding quality monitors ____/10
Investigate potential fraud and abuse with rejections ____/10
Justify the application of the AHIMA Code of Ethics ____/10
Describe the role of the Health Information professional to coding quality,
compliance and reporting ____/5
Describe the role of the provider to clinical documentation improvement ____/5
Relate the importance of computer assisted coding (Encoder Pro) to coding
quality and facility reimbursement ____10
Evaluate significance of coding quality monitors reporting to facility
reimbursement ____/10
Total Points: ____/100
Instructor: __________________________________ Date: __________________
Additional reading materials:
Collecting Root Cause to Improve Coding Quality Measurement” by AHIMA
Coding and Quality Reporting: Resolving the Discrepancies, Finding Opportunities by Nelly Leon-Chisen, published by AHIMA
The Value of a Complete Coding Quality Audit Program by Lisa Marks published by Precyse
Summary of rejection issue, findings and recommendations :
Relate your understanding of coding quality, reimbursement and compliance in a clear, concise statement that illustrates their interrelationship. Steps to answer: Define coding quality, reimbursement and compliance. Connect coding quality with reimbursement; connect coding quality with compliance; connect reimbursement with compliance. Explain how coding quality, reimbursement and compliance are connected with each other.
Justify the need for accuracy in the coding process and all appropriate physician documentation to discuss the interrelationship between these two areas. Answer the following: Enumerate the steps to determine diagnostic and procedural codes are accurate? What is the role of physician documentation? Identify the steps to resolve physician documentation issues.
Discuss the purpose and function of Coding Quality Monitors and their importance in the quality assessment of the coding process. Answer the following questions: Why do we need to monitor weekly rejections such as non- compliance to LCD policy showing medical necessity, incomplete or missing physician documentation, insurance carriers reimbursement policy, NCCI edits for multiple procedures? What are the steps to monitor weekly rejections? What are the steps to resolve weekly rejections?
Rejection Issue
CPT 93880 – Carotid Dopplers
Unspecified carotid artery ICD-10-CM diagnosis code I65.29 were denied as not medically necessary

CPT 57150 – Irrigation of vagina and/or application of medicament for treatment of bacterial, parasitic, or fungoid disease
The documentation for CPT 57150 Is not supported by the CPT definition and is being billed with CPT code 57160 – Fitting and insertion pessary/other vaginal support device for vaginal/pessary washing

ICD-10-CM diagnosis code L20.83 – Infantile eczema
L20.83 rejected for 2-year-old by United Healthcare Partners which is only payable for age 0 – 11 months

CPT 43246-80 – EGD with directed placement of percutaneous gastrostomy tube
Assistant surgeon (mod 80) denied for non-covered service. Per Medicare, payment restriction for assist at surgery applies for this procedure unless supporting documentation is submitted.