MEDAILLE MEMORIAL HOSPITAL

HIA 407E
Team One
Coding Audit Plan

Under the Hospital Acquired Conditions provision of the IPPS, the Secretary of Health and
Human Services has designated several conditions that, when acquired during hospital
admission, have the potential to reduce MS-DRG payment. Included in these conditions is
pressure ulcers (ICD-9-CM codes 707.0X). In order to identify whether the condition was
present when the patient was admitted, or acquired during their inpatient stay, a present on
admission (POA) indicator for each diagnosis should be reported.
After collecting and analyzing data, it is clear that there has been an alarming trend regarding the
assignment of POA indicators, which may be the result of incomplete or inaccurate physician
documentation or quality of care issues. These issues are of concern, as they may lead to
implications of poor quality of care and a decrease in our hospitals reimbursement, and CMS
will not pay the CC/MCC DRG for HACs coded as U or N for the POA indicator.
In order to determine the underlying cause of the inconsistencies surrounding Medaille Memorial
Hospitals POA reporting of pressure ulcers, a medical record audit is advised.
Audit Team
The audit team will consist of representatives from pertinent hospital departments including:

Health information management

Coding department
Physician Champion
Nursing department
Quality Improvement
Compliance

Sample Size
A sample size of 50 records to be pulled from a pool of 93 records studied over the last six
months (2/14-7/14). These records are of interest as they have a high frequency of U,
unknown or N, no POA indicators as related to pressure ulcers. This medical record review
will be retrospective.

Review Process
Each selected record will be reviewed by the auditor for the accuracy and completeness of
documentation pertaining to pressure ulcers. The auditor will assess the record to ensure that all
physicians are following the specific guidelines for documentation. Specific documents to be
reviewed include admission notes/records, physician/nursing progress notes, history and
physicals, emergency room records, and consultation notes, as directed by the audit review sheet.
Particular attention should be given to ensure that assignment of POA indicator is based on
physician documentation only.
When reviewing medical records, areas needing particular attention include:

Medical conditions present or diagnosed prior to admission, such as through an ER

encounter

Conditions documented as suspected, possible, probable, or to be rules out

Underlying causes of signs or symptoms present on admission

Differential diagnoses

The medical record will also be reviewed for the presence of physician query forms and
appropriateness and timeliness of the response. The accuracy of POA indicator assignment will
also be assessed as will the accuracy of coding.
These records will be pulled by HIM staff under the direction of the HIM director. Records will
be individually assessed using the POA audit review sheet which will be signed and dated by the
auditor. Audit team will review audit sheets comments and recommendations, compile, track
and compare information. The results will then be reviewed by the HIM director. This review
process should be done ethically and professionally so as to have an accurate representation of
the data collected.
Results
A report documenting the findings of the audit, specifically the results from the medical record
review, physician query review and review of coding accuracy, will be presented in meetings to
the HIM department and coding staff, as well as to physicians and nursing staff. The identified
issues will be addressed, as well as the corrective actions, will be addressed in staff meetings. If
necessary, physicians, medical staff and coding staff will also be met with on an individual basis
so as to specifically review problematic areas.

Corrective Action
Policies and procedures will be updated to address any problematic issues that are discovered by
the audit process. The problems that are identified will be closely monitored over the next year,
and another audit will be completed at that time, or sooner if necessary, to ensure improvements
in our POA reporting process. Continuous, ongoing staff education programs regarding medical
record documentation, POA assignment processes and updates and clinical coding will be put in
place.
A CDI program will be implemented for physicians and medical staff to develop strategies for
improving concurrent documentation. The CDI program will stress the importance of timely,
accurate and complete documentation as well as focus on POA related documentation
Coder education will include of a review of POA guidelines, references to ICD-9-CM guidelines
on POA indicators and guidelines on the coding of pressure ulcers based on staging.
Policies and procedure regarding the physician query process will be updated as warranted.
Coders and physicians will undergo appropriate education and training to assure compliance and
understanding of this important process.
A regular tracking program will be implemented to ensure POA accuracy going forward. In
addition, a process to monitor the appropriateness of queries and their physician responses will
be implemented as well.
If physicians and/or coders are found non-compliant with the above documentation/POA
indicator improvement initiatives, corrective actions will be implemented department and facility
heads.

References:
http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_047376.hcsp?
dDocName=bok1_047376
http://ahimaltcguidelines.pbworks.com/w/page/46495042/Audits%20and%20Quality
%20Monitoring
http://library.ahima.org/xpedio/idcplg?
IdcService=GET_HIGHLIGHT_INFO&QueryText=%28audit+plan%29%3Cand%3E
%28xPublishSite%3Csubstring%3E%60BoK
%60%29&SortField=xPubDate&SortOrder=Desc&dDocName=bok1_047259&HighlightType=
HtmlHighlight&dWebExtension=hcsp
http://www.cdc.gov/nchs/data/icd/icd9cm_guidelines_2011.pdf
LaTour, K. M. 2013. Health information management: concepts, principles, and practice
4th ed. Chicago, Ill. AHIMA.