Auditing the coding and abstracting of documents

• US 8,731,954 B2
• Filed: 03/27/2007
• Issued: 05/20/2014
• 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): Morgan, Robert
• Assistant Examiner(s): SOREY, ROBERT A
• Application Number:
  US11/692,093
• Publication Number:
  US 20070226211A1
• Time in Patent Office: 2,611 Days
• Field of Search: 705 2- 3
• US Class Current: 705/2
• 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 performed by a computer of evaluating coded medical documents, the method comprising:

receiving, by a computer, audit parameters comprising an expected coder error level, and receiving an empirically established expected auditor error level of an auditor based on an assessment of the auditor;

selecting, by the computer, a sample batch of coded medical documents for auditing by the auditor, the sample batch of coded medical documents selected from a universe of coded medical documents stored on one or more storage devices, the selection based at least in part on the received audit parameters;

receiving, by the computer, audited medical documents corresponding to the selected sample batch of coded medical documents, wherein the audited medical documents include corrections by the auditor;

calculating, by the computer, a medical document score for each of the audited medical documents based on medical document corrections received from the auditor and applying weighted factors, wherein the weighted factors comprise predefined weights assigned to diagnosis and procedure codes in each of the audited medical documents;

calculating, by the computer, a sample score for the audited medical documents based on a function of the calculated medical document scores;

designating, by the computer, at least one of an upper control limit and a lower control limit based on the expected auditor error level; and

comparing, by the computer, the sample score against the at least one of the upper and lower control limits to determine an acceptability of the sample score.

2. The method of claim 1, further comprising calculating a defect level based on the sample score.

3. The method of claim 2, further comprising adjusting the defect level to account for the expected auditor error level of the auditor.

4. The method of claim 1, further comprising:

repeating the evaluation over a period of time to compile a plurality of sample scores; and

tracking a measure of variance in the compiled sample scores across the period of time.

5. A method of claim 4, further comprising tracking a measure of variance between the auditor and other auditors.

6. The method of claim 1, wherein the medical document corrections and a type of each of the corrections are recorded for the sample batch of coded medical documents.

7. The method of claim 1, further comprising recording the medical document corrections.

8. The method of claim 1, wherein calculating the sample score for the audited medical documents based on a function of the calculated medical document scores comprises obtaining a summation of the calculated medical document scores.

9. The method of claim 1, further comprising designating a quality of the coding process, accounting for the error level of the auditor, as being one of an acceptable quality, a marginal quality, and an unacceptable quality.

10. The method of claim 1, wherein calculating the medical document score comprises obtaining a summation of the weighted factors.

11. A system of evaluating coded medical documents, the system comprising:

a user interface device; and

one or more computers communicatively coupled to the user interface device, the one or more computers including a processor and a display configured to provide a graphical user interface to an auditor, the one or more computers configured to perform operations including;

receive audit parameters comprising an expected coder error level, and receiving an empirically established expected auditor error level of an auditor based on an assessment of the auditor;

select a sample batch of coded medical documents for auditing by the auditor, the sample batch of coded medical documents selected from a universe of coded medical documents stored on one or more storage devices, the selection based at least in part on the received audit parameters;

receive audited medical documents corresponding to the selected sample batch of coded medical documents, wherein the audited medical documents include corrections by the auditor;

calculate a medical document score for each of the audited medical documents based on medical document corrections received from the auditor and applying weighted factors, wherein the weighted factors comprise predefined weights assigned to diagnosis and procedure codes in each of the audited medical documents;

calculate a sample score for the audited medical documents based on a function of the calculated medical document scores;

designate at least one of an upper control limit and a lower control limit based on the expected auditor error level; and

compare the sample score against the at least one of the upper and lower control limits to determine an acceptability of the sample score.

12. The system of claim 11, wherein the one or more computers are further configured to calculate a defect level based on the sample score.

13. The system of claim 12, wherein the one or more computers are further configured to facilitate adjustment of the defect level to account for the expected auditor error level of the auditor.

14. The system of claim 11, wherein the one or more computers are further configured to:

allow a repeat of the evaluation over a period of time to compile a plurality of sample scores; and

track a measure of variance in the complied sample scores across the period of time.

15. A system of claim 14, wherein the one or more computers are further configured to track a measure of intra-auditor variation.

16. The system of claim 11, wherein the medical document corrections and a type of each of the corrections are recorded for the sample batch of coded medical documents.

17. The system of claim 11, wherein the graphical user interface is configured to facilitate recording of the medical document corrections.

18. The system of claim 11, wherein the one or more computers is further configured to facilitate the calculation of the sample score for the audited medical documents based on a function of the medical document scores comprising a summation of the calculated medical document scores.

19. The system of claim 11, wherein the one or more computers are further configured to define a quality of the coding process, accounting for the error level of the auditor, as being one of an acceptable quality, a marginal quality, and an unacceptable quality.

20. The system of claim 11, wherein each medical document score comprises a summation of the weighted factors.

21. A non-transitory computer readable medium storing instructions that when executed by a computer cause the computer to perform operations comprising:

receiving an empirically established expected auditor error level of an auditor based on an assessment of the auditor;

selecting audit parameters comprising an expected coder error level and the empirically established expected auditor error level of the auditor;

selecting a sample batch of coded medical documents for auditing by the auditor, the sample batch of coded medical documents selected from a universe of coded medical documents stored on one or more storage devices, the selection based at least in part on the selected audit parameters;

receiving audited medical documents corresponding to the selected sample batch of coded medical documents, wherein the audited medical documents include corrections by the auditor;

calculating a medical document score for each of the audited medical documents based on medical document corrections received from the auditor and applying weighted factors, wherein the weighted factors comprise predefined weights assigned to diagnosis and procedure codes in each of the audited medical documents;

calculating a sample score for the audited medical documents based on a function of the calculated medical document scores;

designating at least one of an upper control limit and a lower control limit based on the expected auditor error level; and

comparing the sample score against the at least one upper and lower control limits to determine an acceptability of the sample score.

22. The non-transitory computer readable medium of claim 21, further operable to cause the computer to calculate a defect level based on the sample score.

23. The non-transitory computer readable medium of claim 22, further operable to cause the computer to adjust the defect level to account for the expected auditor error level of the auditor.

24. The non-transitory computer readable medium of claim 21, further operable to cause the computer to perform operations comprising:

repeating the evaluation over a period of time to compile a plurality of sample scores; and

tracking a measure of variance in the sample scores across the period of time.

25. The non-transitory computer readable medium of claim 24, further operable to cause the computer to track a measure of variance between the auditor and other auditors.

26. The non-transitory computer readable medium of claim 21, further operable to cause the computer to perform operations comprising embedding the corrections within the sample batch of coded medical documents.

27. The non-transitory computer readable medium of claim 21, further operable to cause the computer to perform operations comprising facilitating recording of the received corrections.

28. The non-transitory computer readable medium of claim 21, further operable to cause the computer to facilitate calculation of the sample score for the audited medical documents based on a function comprising a summation of the calculated medical document scores.

29. The non-transitory computer readable medium of claim 21, further operable to cause the computer to define a quality of the coding process, accounting for the error level of the auditor, as being one of an acceptable quality, a marginal quality, and an unacceptable quality.

30. The non-transitory computer readable medium of claim 21, further operable to cause the computer to calculate each medical document score by summing the weighted factors.