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Integrating Information Governance Practices into the Coding Process By Mary H. Stanfill, MBI, RHIA, CCS, CCS-P, FAHIMA

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ONE OF THE goals of information governance (IG) is to continuously improve the value and trustworthiness of the information asset by ensuring that data and content are valid, accurate, reliable, current, and comprehensive. Another goal is to improve the efficiency and quality of data collection, capture, and downstream information use and reuse.1 Thus, it’s no wonder that one of the drivers of IG is ICD-10-CM/PCS implementation. In a recent landmark survey and whitepaper, “2014 Benchmarking White Paper on Information Governance in Healthcare: A Call to Adopt Information Governance Practices,” which was completed by Cohasset Associates in conjunction with AHIMA, 92 percent of survey participants affirmed that highvalue information is required to respond to a changing payment environment, and there is a growing need to analyze clinical, quality, and business performance.2 Case studies from healthcare organizations with active IG programs, collected by AHIMA, further substantiate the survey findings. The case studies illustrate that healthcare organizations that have initiated IG programs have done so to support a wide range of business strategies related to managing quality, improving financial outcomes, and maintaining regulatory compliance.3 Both the survey and case studies underscore a growing need for more precise information to ensure healthcare organizations can meet not only patient care goals but also business and financial goals. This article offers a real-life example to illustrate how rapid ICD-10-CM/PCS implementation without IG will result in information integrity loss and provides specific suggestions for how to integrate IG practices into the ICD coding process. Ensuring the quality of ICD coded data is an IG task. Information governance is defined as “the specification of decision 62 / Journal of AHIMA November–December 14

rights and an accountability framework to ensure appropriate behavior in the valuation, creation, storage, use, archiving, and deletion of information. It includes the processes, roles and policies, standards, and metrics that ensure the effective and efficient use of information in enabling an organization to achieve its goals.”4 Given the competing—and often conflicting—priorities guiding the assignment of ICD codes, IG principles outlined in this definition are critical for the ICD coding process.

Need for IG in ICD Coding The following case example illustrates the ICD data integrity issues that may arise without consensus on data capture priorities, decision rights, and accountability derived from sound IG practices. Actual inpatient case scenario: a 90-year-old female was admitted through the emergency department with diagnoses on admission of both atrial fibrillation and pneumonia. An additional final diagnosis on discharge was acute heart failure. The patient expired. Applicable classification standard: “…when two or more diagnoses equally meet the criteria for principal diagnosis… any one of the diagnoses may be sequenced first.”5 Two possible correct coding results: –– Option A:

-- Principle diagnosis: ◆◆ J18.9 pneumonia, unspecified organism -- Secondary diagnoses: ◆◆ I48.91 unspecified atrial fibrillation ◆◆ I 50.41 acute combined systolic (congestive) and diastolic (congestive) heart failure

-- DRG result: ◆◆ 193 Simple pneumonia and pleurisy w/ MCC ◆◆ Relative weight: 1.4893 (v30) ◆◆ Severity of illness = 3 ◆◆ Risk of mortality = 3 –– Option B:

-- Principle diagnosis: ◆◆ I48.91 unspecified atrial fibrillation -- Secondary diagnoses: ◆◆ J18.9 pneumonia, unspecified organism ◆◆ I50.41 acute combined systolic (congestive) and diastolic (congestive) heart failure -- DRG result: ◆◆ 308 Cardiac arrhythmia and conduction disorders w/ MCC ◆◆ Relative weight: 1.2285 (v30) ◆◆ Severity of illness = 4 ◆◆ Risk of mortality = 4 This case example is a real inpatient case where clinical documentation supported the principal diagnosis code for either pneumonia or atrial fibrillation, with very different DRG results. Thus this case could be coded as in option A or B and remain compliant with coding classification standards and official guidelines since both conditions occasioned the admission to the hospital and both conditions were treated throughout the inpatient stay. Which diagnosis is deemed to be the principal diagnosis for coding and reporting purposes may be different depending on the healthcare facility’s IG strategy. Information governance would provide coding operations with a framework to address the conflicting coding options in this case in order to align with clinical and business priorities. For example, if the facility is financially driven they would likely code the case as in option A, where the DRG payment is higher with a relative weight of 1.4893. However, if the facility is more focused on their ranking based on risk of mortality, they would likely code the case as in option B, where the risk of mortality for this patient who expired is appropriately a level 4. Without an IG framework, the case might be arbitrarily assigned to one of the two options. In this particular case, precious resources were consumed by hospital staff debating the correct coding since no data strategy had been defined and the ultimate responsibility and accountability for driving data decisions and achieving consensus was not clear. The rapid adoption of electronic health records (EHRs) in recent years without adequate policy and governance infrastructure has resulted in growing data concerns.6 Likewise, without sound IG practices applied to ICD coded data, increasing data problems are likely—including skewed reimbursement groupings or unexplainable quality report cards. Though most health-

care organizations have not yet established a comprehensive strategy for IG, according to the aforementioned IG in healthcare survey, HIM professionals can apply IG principles to ensure ICD coded data integrity.

Applying IG to ICD Coding HIM professionals can initiate IG practices for ICD coding by documenting all ICD data uses and users, including reports and various ways coded data will be interpreted, and evaluating them to identify potential conflicts and variances that need to be addressed through policy or standards. For example, coding professionals need to identify a principal diagnosis of heart failure for correct MS-DRG assignment and quality professionals need to identify cases of heart failure to monitor compliance with core measures. Thus, alignment and agreement on the principal diagnosis between coding for the healthcare claim and the quality department is needed along with responsibility for addressing ambiguity in the clinical documentation. An inventory of all possible uses of ICD data will help the organization develop policies and protocols to continuously improve ICD information integrity and quality. An interdisciplinary approach, involving representatives from quality, finance, and HIM, at a minimum, is necessary to achieve a comprehensive inventory. A formalized committee structure is recommended to establish responsibility for driving decisions to achieve consensus and accountability. Another concrete action HIM professionals should take is to evaluate existing policies and procedures to determine if the current approach will meet all the intended primary and secondary uses of ICD coded data. For example: –– Is there a policy for determining the principal diagnosis when faced with conflicting options, as in the case example presented earlier in this article? –– Do existing policies and procedures sufficiently address new codes and incorporate code set changes? –– W hat class IV procedures are captured with ICD and who uses this data? –– Is there redundancy between data captured with ICD and other code sets? If so, which is the more appropriate source data? This evaluation of existing policies and procedures will identify new processes and controls to be implemented, potentially at the enterprise level. Good communication and leadership with an interdisciplinary approach will ensure that solutions can be developed to serve all departments within the organization. For instance, if blood products for transfusions are captured when dispensed with healthcare common procedure coding system (HCPCS) codes, is there any need to also capture ICD proceJournal of AHIMA November–December 14 / 63

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dure codes for transfusions? Which department will retain the responsibility and accountability for accurately reflecting transfused substances? These are a few specific suggestions to integrate IG practices into the ICD coding process today. Begin to apply these practices to continuously improve the value and trustworthiness of ICD data by ensuring that data and content are valid, accurate, reliable, current, and comprehensive. HIM professionals are encouraged to take action now as rapid ICD-10-CM/PCS implementation without IG will result in information integrity loss. ¢

Notes 1. Kloss, Linda L. “Leading Innovation in Enterprise Information Governance.” Journal of AHIMA 84, no. 9 (September 2013): 34-38. 2. Cohasset Associates and AHIMA. “2014 Benchmarking White Paper on Information Governance in Healthcare: A Call to Adopt Information Governance Practices.”

http://research.zarca.com/survey.aspx?k=SsURPPsUPQ sPsPsP&lang=0&data=. 3. Kadlec, Lesley. “Coming Soon to Your Healthcare Facility: Information Governance: A Look at Healthcare Information Governance Trends through Practical Case Studies.” Journal of AHIMA 85, no. 8 (August 2014): 26-32. 4. Gartner. “IT Glossary: Information Governance.” 2013. www.gartner.com/it-glossary/information-governance. 5. Centers for Medicare and Medicaid Services. “ICD-10-CM Official Guidelines for Coding and Reporting. Section II. C.” 2014. www.cdc.gov/nchs/data/icd/icd10cm_guidelines_2014.pdf. 6. Butler, Mary. “Keeping Information Clean: New Information Governance Efforts Challenge HIM to Sort Out Dirty Data.” Journal of AHIMA 84, no. 11 (November-December 2013): 28-31. Mary Stanfill ([email protected]) is the vice president of HIM consulting services at United Audit Systems, Inc.

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Average No. of Copies Each Issue During Preceding 12 Months

No. Copies of Single Issue Published Nearest to Filing Date

43,674

46,226

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D. Free Nominal Rate Distribution 1. Outside-County

0

0

2. In-County

0

0

3. Other Classes Mailed through the USPS

0

0

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98

0

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98

0

1. Mailed Outside-County Paid Subscriptions

42,187

44,613

2. Mailed In-County Paid Subscriptions

0

0

3. Paid Distribution Outside the Mails and Other Paid Distribution Outside USPS

299

343

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42,584

44,956

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0

0

G. Copies Not Distributed

1,091

1,270

42,486

44,956

H. Total

43,675

46,226

Percent Paid

99.8%

100%

C. Total Paid Circulation

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