Marshalltown, Iowa POLICY & PROCEDURES Policy Number: P2-01 Subject: Purpose: Inpatient Coding/ Abstracting Process All inpatient records must be reviewed, and appropriate diagnosis and procedure codes assigned for billing and indexing purposes. Information from the Medical Record must be entered or verified in the computer system to assure accurate information on the bill and to establish a database for information retrieval. Materials: ICD-9-CM Code books Medical Records Pencil Coding Questions form Computer Blue Please Complete Inserts Plato Data Analyser Procedure: 1. ABSTRACTING INFORMATION ON REGISTRATION SCREEN Enter account number and proceed to Census, then page 4, enter for : Complete the appropriate fields according to the following information: PHYSICIANS - Review chart and record the physicians involved in the patient's care. Please note that Registration completes the admitting and attending physicians on the face sheet initially. These may not reflect what is actually in the chart, and are corrected in the computer system by Medical Records. 2ND...: This is the physician responsible for the admission of the patient, may or may not dictate H&P (Admitting physician). If EDP admits, the physician he/she admits for is the admitting physician; an EDP should not be admitting physician unless he/she is a regular staff physician and is the patient's physician. In observation situations when the patient has been made an inpatient, it is the physician who writes the actual admit order (excluding EDPs) that is entered in field 17. All charts that have TOR or Observation, as the first order must have the Observation Patient Alert sheet completed and filed with the chart. If no sheet is present, then complete one and put in the UR folder, and file the chart back on the coding shelf. When the sheet has been completed and faxed to the Business Office, process the record and keep the Observation Patient Alert sheet with the record until it is released. The chart cannot be released until the sheet has been faxed to the Business Office. After releasing, remove the sheet and file with the Outpatient Clerk=s collection of Observation Alerts. If you do not know the physician=s 6 digit number, hit Shift? and a list will come into the screen. Type in part of the physician=s last name, and the list will go to that part of the alpha listing. If the physician you want is listed, type in the corresponding selection number next to the name, and the field is filled in. Any time there is a? in the field, you can call in a help table in this manner.
Page 2 FAMILY Physician: Double check the information that may be listed there and if it is not substantiated anywhere in the record, pound out (shift # key, enter), or enter the correct information if documented. DNR...: Enter Y if patient record has an order for DNR/No code. Do not enter N if there is no order; leave it blank. RESTRAIN: Enter Y if the patient has a restraint order sheet present. Double check that order sheet for a notation in the right lower corner reflecting that it has been copied. If nothing is documented, copy the orders, permit and flow sheet and forward to Performance Improvement. Once the fields on Page 4 are completed, page down, and type in M to get to the Medical Records Grouper screen (you may have a Hot Key set up to take you there). 2. DRG GROUPER SCREEN ABSTRACTING DISCHARGE STATUS: Check the discharge summary, the discharge instructions and/or the Discharge Planner and the Patient & Family Service notes for the disposition of the patient. Enter H 01/HOME/SELF This category is usually referred to as a routine discharge. It includes the following: a. Patients discharged to home and given recommendations for further diagnostic work-up by another physician on an outpatient basis. b. Patients for whom outpatient treatment arrangements were made. c. Follow-up care in a physician's office or in a hospital-based clinic. d. Patients who have been instructed to return to the emergency department or the physician's office for removal of a cast. e. Referral to another physician for treatment on an outpatient basis (such as psychiatric therapy or allergy treatment). f. Residential or assisted living facilities such as Westwood, State Juvenile Home, Tama County Home (Country Living Care), Custodial Homes, Adolescent Group Homes, jail, Embers, Bickford Cottages, Glenwood Estates. This category implies that the patient has been discharged to a household residence. Therefore, it would also be used for any patient whose normal place of residence was different that a household residence. It includes those individuals discharged to care of relatives/family, a foster home, adoption agency, retirement home, or in the custody of law enforcement officials.
Page 3 X 02/OTHER ACUTE HOSPITAL This category includes a patient who was transferred to another acute care hospital (general or specialty). Patients discharged from SNF and admitted to acute care should be X. Specific Acute care hospitals we transfer to have been further identified by their specific code instead of X (for psychiatric transfers, see Other Health Care Facility listing) 1 Iowa Methodist Medical Center 2 Mercy Medical Center (Des Moines) 3 Iowa Lutheran (Des Moines) 4 Other Acute 5 Cedar Rapids 6 Mayo Hospitals in Rochester 7 University of Iowa Hospital 8 Mary Greeley Medical Center N U O 03/SKILLED NURSING FACILITY This category includes a patient who was discharged to a skilled level of care; be aware that some local nursing homes have skilled beds. These can include Marshalltown Grandview, Southridge, Oakview in Conrad, State Center Manor, and Valley View in Eldora. Review the discharge orders and instructions to determine level of care, call all facilities to see if status was changed. 04/INTERMEDIATE CARE FACILITY This category includes a patient who was discharged to an intermediate level of care. Specific ones have been further identified by using the following instead of U: K Grandview - Marshalltown J Villa del Sol - Marshalltown S Southridge - Marshalltown M Sunny Hill - P Oakview - Q Grandview - Tama R SCM V Valley F Eldora Manor C Colonial Manor, Baxter G GCL W Acres U Nursing Home - any other nursing home I Iowa Veterans Home 05/OTHER HEALTH CARE FACILITY This category includes a patient who was referred or transferred to another type of health care facility other than those mentioned above; e.g. Half-Way House for Alcoholics, TB Sanitarium, psychiatric (exempt) unit. Transfers for mental health care are included in the quarterly acute transfer review. Mary Greeley Mental Health Younker's Rehab Schoitz Rehab Ames Rehab
Page 4 VA Hospitals Cherokee/Independence/MECCA Iowa Lutheran Mental Health University of Iowa, Psychiatric If questions on unlisted facilities, refer to the Health Care Facilities in Iowa book. A L E 06/HOME WITH ASSISTANCE FROM AN ORGANIZED HOME HEALTH SERVICE All patients who were transferred or referred to an organized home care service should be included in this category. (It applies whether or not the service is a hospital-based program.) This includes Hospice. 07/AGAINST MEDICAL ADVICE This category is used to indicate all patients who refused further medical care and left the hospital. The patient may or may not have signed a release form responsibility statement. It also includes those patients who eloped; that is, left the hospital without informing any members of the hospital staff. 20/EXPIRED Update field 3 as appropriate. Admit Type: update as appropriate. Enter B D E N H U Newborn Urgent - Direct admit to floor or ICU from outside (home or office) To ICU from ED, or ED - TOR - ICU Elective Surgery, OPS - Admit Skilled Care Facility (all) To floor from ED, ED - TOR - Admit Check the chart for ED triplicate to see if patient came through ED Service: Driven by attending physician (excluding Trauma and Skilled Services): Enter J Medical K General Surgery L Obstetrics M Newborn N Pediatric O Orthopedic / Podiatric P Gynecology Q Urology R ENT/EYE/Dental S Skilled Care (all Skilled patients are S) T Trauma (all patients determined to be Trauma injuries are T) ATTENDING PHYSICIAN: The attending physician is the surgeon when an operation has been performed
Page 5 (EXCEPTION may be a diagnostic procedure by a consulting physician, i.e., gastroscopy or cystoscopy when another physician is following the case). In cases where no surgery is performed and it is not clearly evident which physician provided Athe majority of care@, the physician discharging the patient from the hospital will be considered the attending. If a physician notes that ADR TO DO SUMMARY@ in last progress note or order, that designated physician is generally going to be the attending. Also consider which physician will be doing follow-up in those questionable situations. DELIVERING PHYSICIAN is the ATTENDING for all OBSTETRICAL cases. Questions may arise on difficult cases. Consult your Department Director when you are uncertain. The Type for field 11 will always be A Other physicians: Look through consults, Emergency reports, progress notes. If the attending physician has performed a procedure, he needs to be listed again as physician type S. ADDITIONAL PHYSICIANS / TYPES Types are recorded by the letter in parentheses. OTHER ATTENDING: (O) Assists in treatment of the patient, personal physician or covering rounds for another group practice. Must make progress note entries to count, or be assisting physician in surgical cases. Make sure to enter O the letter, not zero the number. CONSULTING: (C) Was asked to see the patient by another physician WHILE IN THE HOSPITAL; writes (may be in progress notes) or dictates a consultation. Psych evaluations are considered consultations, and the staff who did it should be noted as Consulting (rather than P). EMERGENCY: (E) All physician(s) who treat the patient in the Emergency Department. Check nursing documentation also. ANESTHESIOLOGIST: (N) Administers anesthesia during a procedure, starts IVs, consults on mechanical ventilation, intubates. Check Emergency records for any ED procedure by an anesthesiologist. Anesthesiologist doing intubation, OB spinals, or intrathecal injections need to have the type as S. ALLIED HEALTH PROFESSIONALS: (P) These would be PAs or Nurse Practitioners who see the patient in conjunction with a supervising physician. SURGEON (S): The physician who performed a coded procedure on the patient during the stay. Even if attending or consulting, he/she must be listed again as S type SUPERVISING PHYSICIAN: (V) The physician designated as the allied health professional=s supervising physician - the one who signs the record (the designated physicians to oversee the PA in the Emergency Department).
Page 6 3. CODING Code the chart according to Coding Guidelines with the assistance of the 3M encoder. To access the encoder do the following at the DRG Grouper Screen: Zero out to the Patient Function Screen Select Medical Records Select 3M Other Products and enter Select DRG Finder without CPT and enter This brings you to the Coding Window - DRGFinder Screen of the encoder. When in 3M, follow the instructions on the encoder. The coded information will be transferred to the DRG Grouper Screen after the DRG is computed and Complete has been entered. If your computer has a Function Key set up for access to the encoder, use that function key instead. Function keys should be checked for accuracy after every CPSI update as field selections may change. If questions arise during the coding process, complete a Coding Concerns form to the physician. Update the deficiency slip, pull tags off as appropriate, place a blue ADoctor Please Complete for Billing@ insert into the folder and route to the physician. Responses to the Coding Concerns questions are to be clarified in the medical record, initialed and dated. If a physician refuses to add or clarify, then the questioned diagnosis cannot be coded. When charts have all coding issue resolved, remove the blue ADoctor Please Complete for Billing@ insert and proceed with coding. Up to 10 diagnosis codes are entered in fields. Sequence the principal diagnosis in the first field, and for the rest place the most pertinent first. Up to 10 surgical codes codes are entered on the grouper screen. Sequence the most definitive procedure in the first procedure field. Enter the date of the procedure, then the ICD-9 code. Designate the surgeon for that procedure by entering the second number corresponding to the physician field that the surgeon (physician type S) is listed. Before releasing and final routing of the record from the Coding area, please make certain the following reviews have been completed (see their separate procedures for details): Physician Medical Review (PMR) Surgical Case Review, Designated Discharge to Post Acute Care Providers Anesthesia Review Criteria Based Review 72 Hour Readmits Other random reviews as developed (such as preop evaluation) Skilled Chart Review for hospital services not subject to consolidated billing D. RELEASING THE CHART FOR BILLING
Page 7 When all the diagnoses and pertinent procedures have been coded, entered on the DRG Grouper Screen, and DRG computed, and reviews done then release the bill by completing the finish date field. Enter today=s date either manully or pressing. (period) enter, or by function key. Manually enter your initials or automatically with the function key. Face sheets are printed from Patient Function Screen. Print a new face sheet for the record, and more to distribute to each of the physician groups providing patient care during the stay per the ICD-9 procedure. Replace working face sheet and double-check any written information on the original. Place a red AR@ on the left side of the chart label beneath the name to indicate that it has been released. Make certain that tags and deficiency slips are updated, and route to the appropriate physician. Originated by: Health Information Management Effective date: 12/99 Authorized by: Health Information Management Authorized by: HIM Director Date Revision date: 8/01, 5/07 Review date: 6/04 T\Data\Admin\Shari Grace\HIM Procedures 2006\P2-01 Inpt Coding-Abstracting process.doc