ResiCAT_USER-GUIDE_ACT-edition_2014_92pp

CURRENT DOCUMENT VERSION

D. Abbott J.Holman C.Warr

Version 1.4

August 2014

1st Release revised

ResiCAT User Manual

NOTES

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This document and the information disclosed herein are confidential and proprietary to Resolutions (Int) Pty Ltd. The other parties' confidential or proprietary information may not be used or disclosed to any third party for any purpose other than that specifically authorised in writing by Resolutions (Int) Pty Ltd.

Developed date: December 2013 Revised date: November 2014 Revised by: Cath Warr Due for review: December 2014 or when a new version is released

Authors:

Debbie Abbott and Josephine Holman Health Information Consultants Resolutions (Int) Pty Ltd

Approved by:

Debbie Abbott Director Resolutions (Int) Pty Ltd

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TABLE OF CONTENTS

TABLE OF CONTENTS

2 4 4 5 6 7 9

P URPOSE OF D OCUMENT

1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8

L OGGING O N

F ORGOT YOUR P ASSWORD C HANGING YOUR PASSWORD

S ELECTING ACCESS TO THE G ROUPER

A DDING A U SER D ELETING A U SER L EAVING A P AGE

10 11 12 12 13 13 13 14 17 19 19 20 21 21 26 26 26 27 28 28 29 29 30 30 31 31 32 32 32 36 38 40 42 47 47

HOME PAGE

2

W ELCOME TO R ESI CAT

2.1

DATASET SETUP

3

A UDITING FOR THE F IRST T IME (C REATE D ATASET )

3.1

3.1.1 3.1.2 3.1.3

Import data

Select criteria for subset

Save the dataset

C HECKING THE S TATUS OF A D ATASET M AKING A D ATASET I NACTIVE H OSPITAL D EFINED F IELDS (HDF)

3.2 3.3 3.4

CODING AUDIT

4

A UDIT AFTER INITIAL SELECTION OF DATASET (F IND D ATASET ) N AVIGATION T IPS DURING R ECODING AND C ODING C OMPARISON

4.1 4.2 4.3

C HECK E PISODE D ETAILS

4.3.1 Admission Date and Time 4.3.2 Discharge Date and Time

4.3.3 Date of Birth 4.3.4 Gender 4.3.5 Care Type

4.3.6 HITH, MV Hours, ICU Hours, Admission Weight, Leave Days

4.3.7 Mental Health Legal Status 4.3.8 Mode of Separation 4.3.9 Admission Source 4.3.10 Admission Type 4.3.11 Criterion of Admission

C ODE THE E PISODE

4.4

4.4.1 4.4.2

Diagnoses Procedures

C ALCULATE THE DRG C ODING C OMPARISON

4.5 4.6 4.7 4.8

E RROR L OG B OXES E XPLAINED

C OMPLETE E RROR L OGS

4.8.1

ENTER LOG for code error

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4.8.2 4.8.3 4.8.4 4.8.5

ERROR TYPE

47 49 49 50 52 53 54 54 55 56 58 58 60 62 62 63 64 66 67 68 69

REASON FOR ERROR

NOTES

ERROR LOG not required

4.8.6 Summary of Errors

4.8.7

ENTER LOG for DRG Change

4.9 C HANGING A UDIT D ETAILS 4.10 M ARK AS C OMPLETE

A DD A C OMMENT

4.11

REPORTS

5

EPISODE S UMMARY R EPORT A UDIT S UMMARY R EPORT GROUPED BY CODER REPORT AUDITOR THROUGHPUT REPORT

5.1 5.2 5.3 5.4 5.5 5.6 5.7 5.8 5.9

OUTPUT FILE

ERRORS REPORT

A UDIT DETAIL REPORT D ATASET L ISTING R EPORT

DRG REPORT

5.10 I NCOMPLETE R EPORT

5.11 PRINT HDF SUMMARY REPORT 70 5.12 CODER REPORT 71 5.13 EPISODE FIELD REPORT 75

TROUBLESHOOTING

85

6

6.1 G ROUPER IS NOT WORKING ( ONLY RELEVANT IF USING GROUPER ON PC OR LAPTOP ) 85 6.2 S YSTEM IS HANGING 85 6.3 I MPORT DATA IS NOT IN CORRECT FORMAT 85 7 DEFINITIONS 86 7.1 C LASSIFICATION OF C ODING C HANGES – E RROR T YPE 86 7.2 C LASSIFICATION OF C ODING C HANGES – R EASON FOR E RROR 87

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INTRODUCTION 1.1

P URPOSE OF D OCUMENT The purpose of this document is to provide a guide on how to use and administer ResiCAT, a clinical coding audit tool developed by Resolutions (Int) Pty Ltd. ResiCAT provides software to conduct blind recoding audits of coded datasets..

1.2 L OGGING O N Access to ResiCAT is via the following hyperlink https://www.resicat.com.au/resicat

NOTE: Preference of Web browser is the Internet Explorer.

Before you begin you will be given an email username and password.

Enter the username and password that have been allocated to you.

NOTE: The RESET button on this screen enables you to clear the fields so you can enter new data.

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F ORGOT YOUR P ASSWORD

1.3

If you have forgotten your password, select the ‘Forgot your Password’ hyperlink indicated in the screen shot below.

Enter your email address and click on the GET PASSWORD hyperlink. Your password will be emailed to the email address you entered. You can then click on CLICK HERE TO BEGIN. The standard login screen (shown above) will appear and you can proceed as normal.

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C HANGING YOUR PASSWORD

1.4

If you wish to change your password you must log on, click on the organisation name at the top right, then click on CHANGE PASSWORD in the drop-down menu.

The screen below will appear. Complete the fields, then click on CHANGE PASSWORD.

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S ELECTING ACCESS TO THE G ROUPER

1.5

There are two options for accessing the DRG Grouper: it can be done locally using a grouper loaded on a PC or laptop, or by using the grouper provided by Resolutions via an internet cloud.

Click on the organisation name in the right-hand corner, then select MY ACCOUNT.

When the EDIT YOUR ACCOUNT screen appears, select either LOCAL or CLOUD, as seen below.

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If you select CLOUD, no further action is required. If you select LOCAL in the field labelled 3M Grouper Path, enter or update the pathway to the 3M DRG Grouper on your C: drive. Then click UPDATE. NOTE: This instruction is applicable to those using ResiCAT linked with a grouper on a PC or laptop. In Release 1 this option requires linkage to the 3M DRG Grouper and your default browser must be Internet Explorer.

NOTE: For ResiCAT to work properly you must also ensure that the website address is included as a Trusted Site. To do this, click on the Internet Tools icon in the top right hand corner of your screen. Select ‘Internet Options’ then ‘Security’ then ‘Trusted Sites’. Copy the ResiCAT website address into the box that is displayed.

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A DDING A U SER

1.6

To add a User click on the ‘USERS’ option in the drop-down menu

A list of existing users will appear. The right-hand column labelled ACTION will be blank next to your own entry but the option to ‘Delete’ will be shown next to other entries in the list. Click on the ADD USER button at the top right side of the page. The following ADD USER screen will appear:

Complete the First Name, Surname and Email fields. Tick whether the new user will have Administrator or User level of access, then click on the CREATE USER button.

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The screen will return to the previous list of users and the one you have added should now be included.

The new user will receive an email letting them know they have access to ResiCAT and providing them with a password.

To exit the Users screen, click on DATASET SETUP or CODING AUDIT in the top bar or if you wish to leave the system, click on LOGOUT in the organisation’s drop-down menu.

D ELETING A U SER

1.7

Access the USERS screen as described in 1.6 above. When the list of users appears, click on DELETE in the right-hand Action column for the user you wish to delete. The message ‘Are you sure you want to delete this user?’ will appear.

Click on OK to confirm you wish to delete this user. The screen will refresh and the user you deleted will no longer be listed.

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L EAVING A P AGE

1.8

When you close a screen the message highlighted in the screen shot below will appear:

Click on LEAVE THIS PAGE if you want to close the screen you are on.

NOTE: Data such as codes that you enter are automatically saved as you go along so when you leave a page no ‘Save’ action is required.

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HOME PAGE

2

2.1 W ELCOME TO R ESI CAT Once you log on to ResiCAT you will be presented with the ResiCAT Home Page which provides icons to access the following sections:  Dataset Setup  Coding Audit  Reports  HDF Setup The HDF (Hospital Defined Fields) module enables an organisation to audit fields in its Patient Administration System (PAS) software. It is able to capture data specific to your organisation or state but which are not an integral part of the PAS software. The HDF module is separate and additional to the core ResiCAT software and will only be active if your organisation’s ResiCAT licence includes the HDF module.

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DATASET SETUP

3

A UDITING FOR THE F IRST T IME (C REATE D ATASET )

3.1

3.1.1 Import data The first time you log into the system, you need to select your data source. To begin this process, click on DATASET SETUP.

The screen below will appear.

Click on SELECT FILE. You can then browse to the drive or place where you have stored your selected dataset. Select the dataset and double click. The system will now import the dataset into ResiCAT.

NOTE: The dataset cannot be imported unless it is in the required format. If the format is incorrect a message will appear to advise the user.

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3.1.2 Select criteria for subset When the data import has taken place the screen below will appear.

Note that the program is defaulted to VIEW ALL episodes in the dataset so all the records in the imported dataset will be listed. From this point you have the option to create a subset to work with and/or select a random sample of a defined size from the whole dataset or the subset. You may choose to select episodes to audit by un ticking those you do NOT want. This can be done whether you choose SELECT CRITERIA or not. When you click SAVE only the ticked records will be included in the saved file. If you do not want to select any of the criteria, go directly to the SAVE button. If you wish to choose a subset from the data using certain criteria, tick SELECT CRITERIA. When the screen refreshes a default range of discharge dates will appear, these being from 01/01/1900 to the current date. You can select discharges in a certain date range by entering the dates using the calendar provided beside each date box or by typing over the dates that are there, as indicated by the orange arrows in the screen shot below. NOTE: In the Dataset Setup screen the DRG is visible but once you have created and saved your audit dataset, the DRG will not be displayed in the list. This is to ensure the auditor’s code selection is not influenced by knowing what the original DRG was. The original and audit DRGs will both be displayed in the Coding Comparison screen (see Section 4.6).

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Once you have ticked SELECT CRITERIA, you must specify a parameter by choosing one of the options in the PARAMETER drop-down box, indicated by the green arrow in the screen shot above. The options are:

All

   

DRG

Diagnosis Procedure

If you want a random sample, tick the box FROM THIS DATASET DO YOU WANT TO SELECT RANDOM SAMPLE? When you tick the box the total number of records in the dataset will appear next to ENTER SAMPLE SIZE. Delete that number and enter the sample size you want as shown in the screen shot below. NOTE: You must have changed from VIEW ALL to SELECT CRITERIA for random selection to be operative.

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Once you have indicated your criteria, click on GO. The screen will refresh to show the selected list.

The screen shot below is an example of a subset that has been selected by DRG.

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3.1.3 Save the dataset The number of records in the data subset created by the criteria you selected is shown under SAVE DATASET, # of records.

When saving a file you must make a selection in the HDF field even if your licence does not include the HDF module. Select NO HDF FIELDS as shown below. If you do have the HDF module, select a configuration for the HDF fields from those you have set up beforehand.

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Choose the DATA VALUE TYPE of your dataset from the drop-down menu which lists common types of formats of audit data e.g. VIC -VAED, NSW – ISC - or as shown in the screen shot below.

The Data Value Type you select here controls the values in the drop-down menus accessed during the coding phase of the audit and the overall format of the stored data.

It is mandatory to select a Data Value Type. If you don’t, the dataset cannot be saved and an error message will appear.

At this point there are two tick boxes (indicated by the arrows in the screen shot above):  If you want to be able to enter a diagnosis code more than once, tick the first box labelled ALLOW DUPLICATE DIAGNOSES.  If you want to be able to audit the Condition Onset Flag, tick the second box labelled AUDIT COF. In the field labelled HOSPITAL NAME enter the hospital’s name and in the field labelled NAME, enter a name for the dataset. The name you enter at this point will be the file name you use to retrieve the dataset at the next stage. As you may create any number of subsets from the full dataset, it is recommended that you name the file in a way that will assist in identifying its contents.

A message will appear to let you know that the dataset has been saved successfully.

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C HECKING THE S TATUS OF A D ATASET

3.2

The status of a dataset can be checked at any time. Click on the CODING AUDIT button then click on SEE ALL DATASETS.

The following screen will appear:

As seen in the screen shot above each dataset shows:  Dataset name  Number of episodes in the dataset  Date the dataset was created  Data value i.e. the format that will govern the display of data  Whether duplication of diagnosis codes is allowed  The status of the file i.e. Active or Inactive

M AKING A D ATASET I NACTIVE

3.3

The default for a dataset is Active. To make a dataset inactive click on ‘Active’ for the relevant dataset and it will change the status to ‘Inactive’.

An Inactive dataset cannot be opened by a person with User level access to ResiCAT but an Administrator can change the status back to ‘Active’ by clicking on ‘Inactive’.

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HOSPITAL DEFINED FIELDS (HDF)

3.4

If you purchase the licence for the HDF module you will be able to audit specific parameters through ResiCAT at the time of conducting the coding audit.

The HDF fields are defined by the hospital and require a description, value type and value as seen in the screen shot below. The HDF fields must be set up prior to the commencement of auditing to enable the collection of the data.

The HDF fields are set up to be audited at the time of coding as seen in yellow in the screenshot below

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CODING AUDIT

4

A UDIT AFTER INITIAL SELECTION OF DATASET (F IND D ATASET )

4.1

NOTE: The system will automatically log you out after 30 mins if you are not actively using it.

Once you have selected and saved your dataset you are ready to audit. Click on CODING AUDIT at the top of the screen.

There are two ways of finding the dataset you wish to audit. 1. Type the exact name of the dataset you want into the blank box then click on FIND. 2. If you are unsure of the name of the dataset click on SEE ALL DATASETS.

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When you click on See All Datasets, a list of the datasets to which you have access will be displayed. Select the dataset you want by highlighting it with the arrow key as shown below and double click.

Once selected by either method, the episodes in the dataset will be displayed as shown in the screen shot below. Note that the DRG is not displayed in this list.

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The following screen shot shows what the Coding Audit screen might look like while an audit is in progress:

When the list of records in the dataset first appears all episodes will be listed as ‘Un-audited’ in the Status column and ‘Audit’ will be written in the left-hand column.

If an episode has been opened but not completed, the Status column will show it as ‘Incomplete’ and the left-hand column will still say ‘Audit’ . An Incomplete episode may or may not have codes entered by the auditor, but it has not been grouped. When the episode has been coded and grouped by the auditor but not marked as Complete the episode will display in the list as ‘Grouped’ . The Error Logs may or may not have been completed (see Section 4.6). The left-hand column will display as ‘View’ . When the episode has been fully audited and the ‘Mark as Complete’ button has been clicked (see Section 4.7), the Status column will say ‘Audited’ and the left-hand column will display as ‘View’ . The name of the auditor who last worked on an episode will appear in the ‘Last Auditor’ column for those records shown as ‘Incomplete’ , ‘Grouped’ or ‘Audited’ . A date will only appear in the Date Audited column when the episode has been marked as complete. NOTE: Statistics relating to the audit are only calculated on records marked as complete. Reports provided by ResiCAT are described in Section 5. If your licence includes the HDF module the status of auditing of the HDF fields will also be displayed in a similar manner as can be seen in the screen shot above.

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If you wish to print the list of records in the dataset you have opened, click on the PRINT DATASET button (circled in red in the screen shot below). The Print Options screen will appear.

To commence (or resume) the audit, select the first episode listed (or any record shown as incomplete in the list) by highlighting it with the arrow key and double clicking.

You can find a particular record by entering it in the box labelled FIND UMRN (circled in purple in the screen shot below). As soon as the system recognises the number it will display this record. Double click on the line to begin auditing this record.

NOTE: Clicking on VIEW in the LOGS column enables you to see an audit trail of changes the auditor has made during the audit process.

NOTE: When you open an episode displayed as Grouped or Audited, the episode opens on the Coding Comparison screen, that is, it skips the code entry screen displayed in the next screen shot.

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When you have selected an Unaudited or Incomplete episode the following screen will appear. The imported details for the episode will be displayed on the left-hand side in the EPISODE DETAILS box. Note that, for an episode marked as Incomplete, any data previously entered or changed will have been saved and will be displayed.

The steps of the recoding and audit process are then: 1. Check Episode Details and amend any item that is incorrect. 2. Code the Episode , entering the selected codes in the appropriate boxes. 3. Calculate the DRG. 4. Click on the Coding Comparison button. The system will then display the original set of codes and DRG and those entered by the auditor and any differences will be highlighted. 5. Complete the Error Log for any discrepancy identified including change of DRG. 6. Click on the Mark as Complete button to indicate you do not want to make any changes. 7. Add Comments about the episode if desired. NOTE: You can return to the Coding screen to amend the auditor’s coded data but will have to recalculate the DRG if you do so. To protect the integrity of the blind recoding audit methodology, an audit trail is maintained of any changes made to the auditor’s codes after the initial data entry.

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4.2 N AVIGATION T IPS DURING R ECODING AND C ODING C OMPARISON

If you need to go back to the previous screen, click on the BACK tab on the bottom left-hand corner of the screen as seen in the screen shot below.

The NEXT button in the bottom right-hand corner will take you to the Coding Comparison screen but you will NOT be able to go to the Coding Comparison screen until codes are entered and the CALCULATE DRG button has been clicked and a DRG generated. This ensures that the results are not compromised and a true blind audit has been conducted. 4.3 C HECK E PISODE D ETAILS

Data fields that a hospital may wish to audit are listed under the EPISODE DETAILS section on the left-hand side of the screen. Some fields may impact on the DRG.

If a data item is not correct, you should change it so that the correct data is displayed. Any item you change will be highlighted in orange. When you move to the Coding Comparison screen a comparison of the episode details will appear and any difference will be highlighted in purple.

4.3.1 Admission Date and Time The first listed data field is ADMISSION DATE / TIME. If the data displayed is incorrect the auditor can type over the admission date that is there or change the date by clicking on the calendar and selecting the correct date as shown below.

To change the admission time, simply type over the admission time shown.

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4.3.2 Discharge Date and Time The next listed data field is DISCHARGE DATE / TIME. If the data displayed is incorrect the auditor can type over the discharge date entered or change the date by clicking on the calendar and selecting the correct date as shown below. To change the discharge time, simply type over the discharge time shown.

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4.3.3 Date of Birth The next data field that can be audited is date of birth, labelled DOB. If this needs changing, type over the date that is there or click on the calendar icon next to the listed date of birth and alter the date as per the screen shot below.

4.3.4 Gender The next data field listed is GENDER. The auditor can select a different gender type by choosing from the drop-down box as shown below.

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4.3.5 Care Type The next data field is CARE TYPE. The auditor can change the care type by choosing from the drop-down box as shown below.

4.3.6 HITH, MV Hours, ICU Hours, Admission Weight, Leave Days The next five data fields – HITH Days, MV Hours, ICU Hours, Admission Weight and Leave Days – may have a value from the original dataset but may be blank. If any item is incorrect the auditor can simply type over, or delete, as in HITH days in the screen shot below.

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4.3.7 Mental Health Legal Status The next data field is MENTAL HEALTH LEGAL STATUS. If this is incorrect, choose the correct value from the drop-down box as shown in the screen shot below.

4.3.8 Mode of Separation The next data field is MODE OF SEPARATION. If this is incorrect, choose the correct value from the drop-down box as shown in the screen shot below.

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4.3.9 Admission Source The next data field is ADMISSION SOURCE. If this is incorrect, choose the correct value from the drop-down box as shown in the screen shot below.

4.3.10 Admission Type The next data field is ADMISSION TYPE. If this is incorrect, choose the correct value from the drop-down box as shown in the screen shot below.

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4.3.11 Criterion of Admission The next data field is CRITERION OF ADMISSION. If this is incorrect, choose the correct value from the drop-down box as shown in the screen shot below.

C ODE THE E PISODE

4.4

4.4.1 Diagnoses To enter your audit diagnosis codes, click into the DIAGNOSIS box. The number 1 will appear next to the Prefix box. The Prefix box will default automatically to P.

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Enter the ICD-10-AM diagnosis codes selected by the auditor.

You do not have to use the SHIFT key or CAPS LOCK key to enter a diagnosis code. It will automatically enter the alpha character as upper case.

Enter diagnosis codes using dots, e.g. Angina NOS I20.9 is entered as I20.9 not I209.

If you enter a code without the dot or the code you enter is not a valid diagnosis code, the program will give you an error message stating it is an invalid code, as shown below.

As you enter a diagnosis code a list of possible codes will appear as illustrated in the screen shot below. Click on the code you wish to enter or continue to type it in.

The next column is the Condition Onset Flag, labelled COF. If you have opted to audit the COF when saving the dataset the default of 2 will be displayed. If you need to change this, click on the number and an arrow for a drop-down box will appear. Options for selection are 1 or 2. See screen shot below.

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Enter the diagnosis codes either by using the TAB button to get to the next row or by clicking in the Prefix column of the next row.

As shown in the following screen shot, P will automatically be displayed and this can be changed if required by choosing one of the options from the drop-down list.

To enter a morphology code you must first change the Prefix to M. An error message will be displayed if you enter a morphology code with the wrong prefix. Similarly, an error message will appear if you start to enter a non-M code with an M Prefix.

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You can change the position of codes in the list by clicking on the code you wish to move then dragging and dropping it to the desired position. If you drag a code into the Principal Diagnosis position the prefix will automatically change to P. The prefix for other codes in the list, however, will not change and may need adjusting by the auditor. If you have entered an incorrect diagnosis code, you can delete it by highlighting the row where the code is entered. You will see a red X in the right-hand corner of the DESCRIPTION box, as shown below.

The system will ask if you are sure. Select OK to delete or Cancel to retain the code.

NOTE: You must have tabbed to the next row to be able to delete or drag a code.

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4.4.2 Procedures Enter the ICD-10-AM procedure codes selected by the auditor. The dash for a procedure code will automatically appear as show in the screen shot below.

If you do not enter a valid procedure code, ResiCAT will give you an error message stating it is an invalid code, as shown below.

Enter the procedure date (if required by your dataset rules). The date format is dd/mm/yyyy. The system will automatically display the forward slopes (i.e. / / ) when you click in the box.

After entering procedure code and date, click in the ‘Code’ column on the next procedure line to enter the next procedure code.

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If you have entered an incorrect procedure code, you can delete it by highlighting the row where the code was entered. You will see a red X in the right-hand corner of the DESCRIPTION box. As with deleting a diagnosis code, you will be asked to confirm that it is OK to delete the highlighted procedure code. See screen shot below.

The sequencing of procedure codes can be altered by dragging and dropping codes.

NOTE: You must have tabbed to the next row to be able to drag or delete a procedure code.

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C ALCULATE THE DRG

4.5

Once all diagnosis and procedure codes are entered, calculate the DRG by clicking on the button CALCULATE DRG. You will NOT be able to go to the Coding Comparison screen until the CALCULATE DRG button has been clicked and a DRG generated. This ensures that the results are not compromised and a true blind audit has been conducted.

NOTE: National Weighted Activity Units (NWAUs) are available for all DRGs. They must be entered prior to commencement of the audit by the administrator.

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NOTE: If you are using a local grouper when the system is calculating the DRG you may get the message below displayed. Click YES to continue.

IMPORTANT: If you exit at any stage during the coding process the data you have already entered will be automatically saved and on the Coding Audit screen the episode will be listed as ‘Incomplete’ if you have not yet calculated a DRG, or ‘Grouped’ if you have calculated a DRG but not completed all stages of the Coding Comparison screen. Even if you do not enter any data or change any episode details the status will change to ‘Incomplete’ from the first time the record is opened until the episode has been grouped (i.e. DRG calculated) or the audit process has been completed (i.e. all logs entered and episode marked as complete).

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C ODING C OMPARISON

4.6

To go to the CODING COMPARISON screen (audit data compared to imported hospital data) click on the button at the top of the screen or select the NEXT tab on the bottom right-hand corner of the screen. The following screen will appear:

The colour coding reflects the type of error: 

Red – auditor’s principal diagnosis is different  Yellow – a code in hospital code set is not in the auditor’s code set  Blue – a code in the auditor’s code set is not in the hospital code set  Orange – change in Condition Onset Flag (if COF is being audited)  Purple – change in data fields audited but not involving a coding error

From the screen shot aboveyou can see that: 

The auditor has entered a different principal diagnosis to the coder (highlighted red). If this code appears in the hospital’s set of codes but is not listed as the principal diagnosis it will also be highlighted in red.  The codes S50.50, W10.9 and U73.9 are highlighted yellow because they do not appear in the auditor’s code set. Where a code highlighted yellow is listed next to a code highlighted in blue there will be two error boxes in the LOG column (see more about this in 4.7 COMPLETE ERROR LOGs).  The codes W10.19, U73.8 and E11.9 are highlighted blue because the auditor has entered a diagnosis, other than the principal diagnosis, that is not in the hospital code set.  The auditor has changed the patient’s gender so the original and auditor’s codes are highlighted in purple.

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 The auditor’s prefixes are highlighted in purple because there is no corresponding prefix in the original code set.  Condition Onset Flags (COF) have been added by the auditor so are flagged in orange because they are different to the original (in this case the original COF was blank in each case).

On scrolling down the screen, you see the following:

The above shows a screen shot of the data fields comparison including DRG and the comparison of procedures.

In this case the auditor has entered an additional procedure code (95550-03) so it is highlighted in blue (i.e. audit code not in hospital code set). The date is highlighted in purple because there is no corresponding date in the original hospital dataset.

Beside each coding error there is a box labelled ENTER LOG. Where codes highlighted in yellow and blue appear in the same line there are two ENTER LOG boxes.

Under the audit DRG there will be an ENTER LOG box if the hospital and audit DRGs are different but in the case in the screen shot above, the DRG has not changed even though the principal diagnosis was different. There are two columns (indicated by the red box in the screen shot above), one for TOTAL CODING LOGS (7 in this case) and one for TOTAL CODING ERRORS (0 in this screen shot). As you complete the Error Logs the figures for TOTAL CODING ERRORS, TYPE OF ERROR and REASON FOR ERROR will change, as described in 4.7 following.

NOTE: All error logs must be completed before the episode can be marked as complete.

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E RROR L OG B OXES E XPLAINED

4.7

When looking for errors, ResiCAT compares codes in the same line and against all codes in the opposing column. Codes must be an exact match, otherwise they will be treated as separate codes and highlighted as described in the section above. When a code highlighted in yellow (hospital code with no match in auditor’s column) appears in the same line as a code highlighted in blue (audit code with no match in hospital’s codes) two Error Log boxes will be displayed. Whenever double logs are displayed, the auditor must determine whether one or two errors are involved.

Following is a series of screen shots which demonstrate possible combinations and the significance of single and double Error Log boxes.

i) Same codes, principal diagnosis the same but additional diagnoses in different sequence = No errors. No Error Log boxes.

ii) Same codes, principal diagnosis different = One error (incorrect principal diagnosis). Auditor’s principal diagnosis highlighted in red, corresponding code in Hospital column also highlighted in red. One Error Log box, displayed alongside Auditor’s principal diagnosis.

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iii) One additional code in Auditor’s column on different line to other codes in Hospital column = One error (missed additional diagnosis code). The additional Auditor’s code is highlighted in blue and one error log box displayed alongside the Auditor’s additional code.

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iv) One additional code in Auditor’s column on same line as a Hospital code that has a matching code in the Auditor’s column = One error (missed additional diagnosis). The additional Auditor’s code is highlighted in blue and one error log box alongside the Auditor’s additional code.

v) One additional code in Auditor’s column and one code in Hospital’s column with no matching code in the Auditor’s column = Two errors (unjustified additional diagnosis code and missed additional diagnosis code). Unjustified additional diagnosis code is highlighted in yellow and missed additional diagnosis code is highlighted in blue. Two Error Log boxes displayed in same line, both required.

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vi) Different but related codes in the same line = One error (incorrect diagnosis code) Hospital’s code highlighted in yellow, Auditor’s code highlighted in blue. Two Error Log boxes displayed in same line, one not required.

vii) Different but related codes not on the same line and one additional diagnosis in Auditor’s column = Two errors (incorrect diagnosis code and missed additional diagnosis code). Hospital code with no match highlighted in yellow and Auditor’s codes with no matches highlighted in blue. Three Error Log boxes, one not required.

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viii) Different but related codes not on the same line and one unjustified code in Hospital’s column = Two errors (incorrect diagnosis code and unjustified additional diagnosis code). Hospital codes with no matches highlighted in yellow, the Auditor’s code with no match is highlighted in blue and Three Error Log boxes, one not required..

The highlighting of coding differences and the display of Error Log boxes occurs in a similar way for procedure codes. In the following examples there are four potential errors because the Hospital and Auditor’s codes do not exactly match. There are however only two real errors, (incorrect procedure code in both cases) involving incorrect selection of type of hysterectomy and ASA for the anaesthetic codes.

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C OMPLETE E RROR L OGS

4.8

4.8.1 ENTER LOG for code error Once the Coding Comparison screen has been reviewed, you must complete a log for Error Type and Reason for Error for each highlighted difference. Click on an ENTER LOG box and the screen below will appear.

4.8.2 ERROR TYPE From the drop-down list, select the appropriate ERROR TYPE. The list of options will vary according to the position and type of code. For example, in the following screen shot the log is for the first-listed diagnosis code so ‘Incorrect principal diagnosis’ is included as an option.

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In the next screen shot the error involves a diagnosis code that is not on the first line so ‘Incorrect principal diagnosis’ is not included as an option but ‘Missing additional diagnosis code’ and ‘Unjustified additional diagnosis code’ have been added.

For errors involving procedure codes, the options for Error Type are ‘Inocrrect procedure code’, ‘Missing procedure code’ and ‘Unjustified procedure code’, as shown in the following screen shot:

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4.8.3 REASON FOR ERROR From the drop-down list select the appropriate REASON FOR ERROR as shown:

4.8.4 NOTES NOTES is a free-text field and is mandatory. Enter notes that will assist in providing feedback to the client when reporting the results of the audit at a later date. In the Audit Summary Report there is the option to include Notes written in the Error Logs as part of the report.

Click SAVE when you have completed the necessary fields.

Following are examples of completed error logs:

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4.8.5 ERROR LOG not required As described in Section 4.7, there will be occasions when an Error Log is not required. In such a case, tick the box ERROR LOG NOT REQUIRED towards the bottom of the screen.

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In the Coding Comparison screen the Error Log box will be replaced by View as shown in the following example screen shots.

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4.8.6 Summary of Errors At the bottom on the Coding Comparison screen there is a summary of the errors identified. The Summary calculates the total errors and reasons for error for all coding differences for the episode. TOTAL CODING LOGS is the total number of log boxes that were displayed on entry into the Coding Comparison screen. This figure will not change when an Error Log is marked as not required. TOTAL CODING ERRORS is the number of Error Logs that have been completed. The totals in the summary fields will be updated as you complete each Error Log. The sum of the figures in ‘Type of Error’ and ‘Reason for Error’ will not match the figure for ‘Total Coding Logs’ until all logs have been completed and will not match if one or more Error Logs have been marked as not required.

In the screen shot above there are still two Error Log boxes to be completed – for procedures 95550-02 and 95550-01 which are additional procedures included by the auditor, so Total Coding Errors in the summary shows 2 compared to Total Coding Logs of 4.

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4.8.7 ENTER LOG for DRG Change If the audit results in a change of DRG, there will be an Enter Log box beneath the audit DRG as shown below. This must be completed before the episode can be marked as complete.

Click on the Enter Log button and complete the screen as demonstrated. Select an Error Type from the drop-down list. Some DRG changes are affected by more than one factor so you must choose which is the most important factor in change of DRG. It is optional to add notes if further explanation is required. Click on SAVE to complete the Error Log.

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4.9 C HANGING A UDIT D ETAILS

You have the ability to go back and change any data fields or audit codes. If you need to do this, a message will appear as shown in the screen shot below.

The system will force you to regroup the episode and re-enter any Error Logs. Click on OK then make the necessary changes and calculate the DRG again. ResiCAT maintains an audit trail of changes made after an episode has been grouped so the integrity of blind auditing can be monitored.

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4.10 M ARK AS C OMPLETE

To finalise an audited episode you must click on MARK AS COMPLETE. An episode will not be included in the audit summary statistics until it has been marked as complete.

You cannot mark the episode as complete without completing all Error Logs relating to coding differences and to the DRG change where applicable.

If you click on Next Episode before you have marked the episode as complete, a prompt will appear asking if you wish to mark the episode as complete.

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A DD A C OMMENT

4.11

When you have marked an episode as complete you are given the option to add a comment about the episode.

If you wish to add a comment about the episode as a whole (e.g. operation report was missing), click on the ADD COMMENT button and add text in the COMMENTS box as shown in the following screen shot, then click SAVE.

It is not mandatory to add a comment.

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After completing the episode, click on the NEXT EPISODE button at the bottom right of the screen. This will bring up the next incomplete episode in the dataset.

If you have a licence for the Hospital Defined Fields (HDF) module and you have chosen to audit these when setting up the dataset, the system will progress to the HDF screen and it must be completed before you can progress to the next episode. If you want to select a different episode, (i.e. not the next one in the list) click on the BACK TO CODING AUDIT button at the top of the screen. This will take you back to the list of records in the dataset and you can then select whichever one you want by double-clicking on it.

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REPORTS

5

In Release 1 of ResiCAT, there were no reports available via the REPORTS icon on the Welcome to ResiCAT home page. However, the following reports are available when you are in the CODING AUDIT screen and are working on an audit dataset;  Episode Summary Report  Audit Summary Report  Auditor Throughput Report  Errors Report  Output File  Dataset Listing Report  Audit Detail Report  DRG Report  Incomplete Report  Coder ID Report 5.1 EPISODE S UMMARY R EPORT When you are in the Coding Comparison screen there is the option to view an Episode Summary Report. This gives you the ability to review the audit details for the episode on screen and also to print it if required.

Click on PRINT EPISODE SUMMARY in the lower left-hand section of the screen.

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The Episode Summary Report will open up and you will be given the option to send this to your printer.

If you just want to view the details on screen, click Cancel on the printing options screen.

The following screen shot gives you) an example of the one-page summary report for the data fields and audited coding.

The Episode Summary Report can be opened regardless of whether the episode has been marked as complete. It will include the logs that have been completed at the time you view the report.

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A UDIT S UMMARY R EPORT

5.2

At the bottom of the Coding Audit screen there is a button labelled PRINT AUDIT SUMMARY REPORT. This gives you the ability to view on screen or print if required. It gives a summary of the progress of the audit and its findings.

When you click on the button a message asking if you want to include the Error Log notes will appear as shown in the screen shot below. If you click YES, all the free-text notes you entered in Error Logs during auditing will be printed at the end of the report, listed by medical record number.

The following three screen shots demonstrate the information available in the Audit Summary Report .

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NOTE: This report can be viewed at any time during the audit process but only those records marked as complete will be included in the statistics.

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GROUPED BY CODER REPORT

5.3

At the bottom of the Coding Audit screen there is a button labelled PRINT AUDIT SUMMARY REPORT. Once you select the PRINT AUDIT SUMMARY REPORT, you can choose which Audit Summary Report Type you would like.

This report gives the option to report coding results for each individual coder.

AUDITOR THROUGHPUT REPORT

5.4

At the bottom of the Coding Audit screen there is a button labelled AUDITOR THROUGHPUT REPORT. This gives you the ability to review on screen, or print if required, a summary of the volume of records audited by the auditor or auditors.

The report will count only those episodes that have been marked as complete.

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OUTPUT FILE

5.5

At the bottom of the Coding Audit screen there is a button labelled OUTPUT FILE. This gives you the ability to export and save the audit data as an Excel spreadsheet.

When you click on OUTPUT FILE, a message will appear at the bottom of the screen asking whether you want to open or save the file and you can proceed as required.

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ERRORS REPORT

5.6

At the bottom of the Coding Audit screen there is a button labelled ERRORS REPORT, which allows examination of the error type and the reason for the error.

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The error report allows you to run the report by the type of error selected in the audit, such as:

The report can also be run by Reason for error as entered in the coding audit, including the reasons outlined below:

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The ERRORS report prints out a list of errors for the selected type such as Incorrect Principal diagnosis as seen below, or reason for error such as Australian Coding Standard

AUDIT DETAIL REPORT

5.7

At the bottom of the Coding Audit screen there is a button labelled AUDIT DETAIL REPORT, which exports into excel and lists all the data items uploaded from the hospital system and entered by the auditor, which makes it useful for data extraction and manipulation.

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D ATASET L ISTING R EPORT

5.8

At the bottom of the Coding Audit screen there is a button labelled DATASET LISTING REPORT

The dataset listing report allows a report sorted by the Terminal number of the computer, standard numerical or discharge date.

The example below has been run by standard numerical which is order of UMRN

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DRG REPORT

5.9

At the bottom of the Coding Audit screen there is a button labelled DRG REPORT ,

The DRG report prints out a summary as seen in the screen below.

The DRG report lists a summary of the coding audit including the number of episodes audited, the number of episodes where a DRG changed, the total number of episodes with one or more errors, total coding errors as well as giving a summary at the bottom which lists the reason for DRG changes.

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I NCOMPLETE R EPORT

5.10

At the bottom of the Coding Audit screen there is a button labelled incomplete report,

The incomplete report gives a listing of all the episodes that have been audited including the records that are grouped, incomplete and unaudited.

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PRINT HDF SUMMARY REPORT

5.11

At the bottom of the Coding Audit screen there is a button labelled Print HDF Summary Report

The print HDF summary report gives a listing of the Hospital defined fields that were audited during the audit process. They needed to be defined and entered before the commencement of the audit to be included and reportable. The report below gives a summary of the audited HDF for an audit. The hospital can select any data to be collected in this field such as blood transfusion consent, informed financial consent, admission classification etc. …

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