Coding Documentation Queries at Western Health

Business Challenge

The Coding staff at Western Health were very keen to implement an electronic way of communicating with Clinicians about documentation queries.  Traditionally this process was done manually on paper at face to face meetings with Clinicians. These meetings were often difficult to organise because of workload and scheduling issues.  Being able to seek clarification on documentation is a vital part of the coding process, and Western Health saw the implementation of BOSSnet as a perfect opportunity to streamline this process.

Solution

Using BOSSnet eForms, Outcome Reports and Documents of Interest, Core Medical Solutions (CMS) were able to develop a simple coding query process.  Coders were able to:

  1. Submit an electronic coding documentation query eForm at the time of coding.  Queries are auto filled with the patient and episode details as well as the name of the Coder generating the query.
  2. Coding queries are then approved by the Speciality Auditor (the expert in that casemix) before being submitted into the DMR using the Documents of Interest work list.
  3. Clinicians are provided with an Outcome Report of unanswered queries, which allows them to launch directly into the appropriate patient and answer the queries using a coding documentation response eForm. Clinicians are provided with the opportunity to answer these queries when and where it suits them or attend the Coding Service for support from the Team.
  4. The response eForm is auto filled with the patient and episode details as well as the name of the Clinician responding to the query. All the Clinician has to do is enter a yes or no response; however, there are also free text fields that enable additional information to be provided where necessary.
  5. The coding query response then becomes part of the medical record and coders review it as part of their coding workflow.
  6. Coders can monitor and follow up on outstanding queries using the Unanswered Queries Outcome Report. This is particularly useful towards the end of the year to ensure full funding is received.

Results

Implementing electronic coding documentation queries allowed Western Health to communicate with clinicians in a timely manner as they are not reliant on paper or manual follow up processes.  Clinicians receive the query and can easily launch into the relevant patients record to review and respond to the query. This can be done from any location that the clinician can access BOSSnet from and is not reliant on face to face meetings with Coding staff. Importantly, electronic queries are legible and auditable, they form part of the medical record and can be used for coding.  The more accurate the documentation is, the more accurate the clinical coding is, and therefore more the accurate the reimbursement.

Since implementing electronic coding queries at Western Health, a number of other clients have chosen to implement this process as well.

"Implementation of electronic coding queries provided a quick and easy method of clarifying documentation, which has resulted in more accurate coding and reimbursement."

Kate Hunt
Coding Manager
Western Health