Auditing the coding and abstracting of documents

• US 10,216,901 B2
• Filed: 05/07/2014
• Issued: 02/26/2019
• Est. Priority Date: 03/27/2006
• Status: Active Grant

• Current Assignee: Optum360, LLC (UnitedHealth Group Incorporated)
• Original Assignee: A-Life Medical, LLC
• Inventors: Heinze, Daniel T., Feller, Peter, Morsch, Mark L.
• Primary Examiner(s): Sorey, Robert A
• Application Number:
  US14/271,719
• Publication Number:
  US 20140257842A1
• Time in Patent Office: 1,756 Days
• CPC Class Codes: G06F 16/93 Document management systems
• CPC Class Codes: G06Q 50/22 Social work or social welfare, e.g. community support activities or counselling services
• CPC Class Codes: G16H 10/00 ICT specially adapted for the handling or processing of patient-related medical or healthcare data for medical reports G16H15/00; for therapies or health-improving plans G16H20/00; for the handling or processing of medical images G16H30/00
• CPC Class Codes: G16H 40/20 for the management or administration of healthcare resources or facilities, e.g. managing hospital staff or surgery rooms
• CPC Class Codes: G16H 50/50 for simulation or modelling of medical disorders
• CPC Class Codes: G16H 50/70 for mining of medical data, e.g. analysing previous cases of other patients
• CPC Class Codes: G16H 70/00 ICT specially adapted for the handling or processing of medical references

Abstract

Techniques for implementing Quality Assurance of the process of coding medical documents are disclosed. An audit of a coding process for a medical document is initiated by selecting and setting audit parameters. Using the selected parameters, a sample batch of coded documents is obtained from a universe of coded documents. The sample batch of coded documents is presented to auditor(s), and the auditor(s) provide corrections, which are recorded, and a score for each correction is calculated. A sample score, based on the corrections, is calculated in a manner that tracks to subjective auditor assessments of the process quality as being acceptable, marginally acceptable, or unacceptable, and which sample score accounts for the individual auditor subjectivity and an error.

Claims

1. A method of evaluating coded medical documents performed by a computer, the method comprising:

providing, by a computer, a graphical user interface (GUI) wizard;

receiving, by the computer via the GUI wizard, audit parameters for selecting a document universe and for calculating a sample size;

calculating, by the computer, a sample size using the received audit parameters;

selecting, by the computer, a document universe based on the received audit parameters;

providing, by the computer via the GUI wizard, a plurality of medical documents coded by a coder and selected using the selected document universe and the calculated sample size;

receiving, by the computer via the GUI wizard, a plurality of corrections by an auditor to the plurality of medical documents;

recording, by the computer, the plurality of corrections to the coded medical documents to form a plurality of audited medical documents;

determining, by the computer, a document score for each of the plurality of audited medical documents, each document score based on one or more document corrections provided by the auditor and weighted factors, wherein the weighted factors comprise predefined weights assigned to diagnosis codes and finding codes of each of the plurality of audited medical documents;

determining, by the computer, a sample score for the plurality of audited medical documents based on the determined document scores;

determining, by the computer, the acceptability of the sample score by periodically performing an empirical test to compare the sample score to system control limits; and

displaying, by the computer via the GUI, an X-bar chart analysis comprising the sample score, an upper control limit, a lower control limit, and a previously determined sample score of audited medical documents coded by the coder.

2. The method of claim 1, further comprising:

determining, by the computer, a defect level based on the sample score.

3. The method of claim 1, wherein the weighted factors further comprise predefined weights assigned to procedure and level of service codes.

4. The method of claim 1, wherein determining, by the computer, a document score for each of the plurality of audited medical documents further includes judging each of the diagnosis codes and finding codes as correct or incorrect.

5. The method of claim 1, further comprising:

judging, by the computer, a modifier code to determine whether the modifier code is of consequence,

wherein the weighted factors comprise a predefined weight assigned to the modifier code.

6. The method of claim 1, wherein the plurality of audited medical documents comprises a sample batch of coded medical documents.

7. The method of claim 1, wherein determining, by the computer, a document score for each of the plurality of audited medical documents further comprises:

determining a number of units associated with a procedure code; and

determining a number of links associated with the procedure code.

8. A non-transitory computer readable storage medium encoded with instructions executable by a processor that when executed instruct the processor to:

generate a graphical user interface (GUI) wizard;

receive, via the GUI wizard, audit parameters for selecting a document universe and for calculating a sample size;

calculate a sample size using the received audit parameters;

select a document universe based on the received audit parameters;

provide, via the GUI wizard, a plurality of medical documents coded by a coder and selected using the selected document universe and the calculated sample size;

receive, via the GUI wizard, a plurality of corrections by an auditor to the plurality of medical documents;

record the plurality of corrections to the coded medical documents to form a plurality of audited medical documents

determine a document score for each of the plurality of audited medical documents, each document score based on one or more document corrections provided by the auditor and weighted factors, wherein the weighted factors comprise predefined weights assigned to diagnosis codes and finding codes of each of the plurality of audited medical documents;

determine a sample score for the plurality of audited medical documents based on the determined document scores;

determine the acceptability of the sample score by periodically performing an empirical test to compare the sample score to system control limits; and

display, via the GUI, an X-bar chart analysis comprising the sample score, an upper control limit, a lower control limit, and a previously determined sample score of audited medical documents coded by the coder.

9. The non-transitory computer readable storage medium of claim 8, wherein the instructions further instruct the processor to determine a defect level based on the sample score.

10. The non-transitory computer readable storage medium of claim 8, wherein the instructions to determine a document score for each of the plurality of audited medical documents further include instructions that instruct the processor to judge each of the diagnosis codes and finding codes as correct or incorrect.

11. The non-transitory computer readable storage medium of claim 8, wherein the plurality of audited medical documents comprises a sample batch of coded medical documents.

12. The non-transitory computer readable storage medium of claim 8, wherein the weighted factors further comprise predefined weights assigned to procedure and level of service codes.

13. The non-transitory computer readable storage medium of claim 8, wherein the weighted factors further comprise predefined weights assigned to at least one of a ranked order of the procedure and level of service codes and a level of the procedure and level of service codes.

14. The non-transitory computer readable storage medium of claim 8, wherein the instructions to determine a document score for each of the plurality of audited medical documents further include instructions that instruct the processor to:

determine a number of units associated with a procedure code; and

determine a number of links associated with the procedure code.