LVF Audits – an Overview - PowerPoint Presentation

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LVF Audits – an Overview

This training is provided by the Missouri Cancer Registry

Disclaimer- Missouri Cancer Registry presents this training as a learning tool for hospital staff who report cancer cases to the central registry. This tool should not be used to determine medical diagnoses. Persons seeking CMEs or CEUs should check with their accrediting organization to determine if this training meets their criteria for educational credits.

This project was supported in part by a cooperative agreement between the Centers for Disease Control and Prevention (CDC) and the Missouri Department of Health and Senior Services (DHSS)

(5NU58DP003924-05) and a Surveillance Contract between DHSS and the University of Missouri.

MCR gratefully acknowledges

Angela Martin,

CTR who developed the Power Point presentation used as the basis for this

training.

Objectives

To understand the purpose of an AuditTo understand the steps in the Audit process

Audits

Required by National Program of Cancer RegistriesEach Missouri hospital is audited within a 5 year time period to assist with casefinding

and abstracting

Audits are for educational purposes, not punitive

Audits

MCR conducts a standard casefinding audit on LVFs – basically we receive your MRDI and compare that to our database

When NPCR conducts an Audit on MCR – a few hospitals will be requested to provide data…the audit is not on your facility but on

MCR

How will I know I am up for an Audit?

A letter is sent to the Facility Contact and Administrator so that he/she will be aware that you are undergoing an audit. We will also contact you via email and phone once letters have gone out. We may request additional information if we do not have it

What will I need?

Medical Record Disease Index. With the MRDI we would normally use the one that was previously submitted with your data submission. If the MRDI is not in the proper format or missing vital information for us to conduct our Audit we will request that another MRDI be submitted. Admission Key/Service Code Report. If

your admission key/service code is a number we do need a report telling us what the number corresponds to. Submission of above within 2 weeks of audit notification

Medical Record Disease Index

Your MRDI should include these fields: First and Last NameDate of BirthSocial Security NumberService CodeAdmission and Discharge Date

Medical Record NumberICD-10 codesProcedure codes (if any)

ICD-10-PCS codes (if any)

EXAMPLE OF MEDICAL RECORD DISEASE

INDEX

NAME

DOB

SSN

SERV CODE

ADM DATE

DIS DATE

MR#

ICD-10 CODES

DESCRIPTION

PROC CODES

DESCRIPTION

AAAA

12/01/50

333224444

OPS

06/15/16

06/15/16

12345

C50.9

Malignant

neoplasm of breast

0HBT0ZZ

Local excision

SURG

07/01/16

07/04/16

12345

C50.9

Malignant

neoplasm of breast

0HTT0ZZ

Right simple mastectomy

C78.7

Secondary liver

mets

0W9930Z

Right

catheter insertion for drainage

I10

Hypertension

BBBB

12/31/69

444556666

OPS

12/01/16

12/01/16

10101

K92.1

Blood

in stool

0DBP0ZX

Open

biopsy of rectum

C20

Malignant

neoplasm of rectum

XRT

12/10/16

12/10/16

10101

Z51.0

Radiotherapy

DD073ZZ

Teleradiotherapy

using electrons

C20

Malignant

neoplasm of rectum

CCCC

01/13/30

111223333

OPS

03/02/16

03/02/16

7777

D33.2

Benign

neoplasm of brain

B030ZZZ

MRI of brain

Medical Record Disease Index

Generating or compiling a useful MRDI may require the help of your IT department. Your software system may produce a text file which you can then be imported into an Excel spreadsheet. The Excel spreadsheet can submitted to us. There are very specific things we request. The MRDI needs to be in alphabetical order by last name

The MRDI should include the social security number

It is also important to annotate the MRDI

Audit Process

ReviewResolutionReconciliation and Finalization

Audit Process

ReviewThe Review portion takes place at MCR We review your MRDI against our database,

and anything that is not present in our database we will

place on a pull list for your facility and will fax to youWe will send an email/call to set up the resolution

call

Audit Process

ResolutionCharts from the pull list for the dates of service specified should be available and ready to discuss during the callEach case will be discussed to

determine whether the case

should be reported. We may ask about several cases that

you correctly found to be non-reportable, which will only confirm your skillsDuring the call, we may create a list of missed cases that would need to be

submitted in the same manner as your regular quarterly submissions. Please note that these are missed cases from the audit by placing those comments

on the transmittal form.

Audit Process

Reconciliation and FinalizationAudit Report sent to facility contact contains kudos, suggestions and completeness rateLetter to administrator notifies them that the Audit is complete

Positives of Audit

Administrator becomes aware of the great job you are doingHelpful tips to improve casefindingOverall

goal is to improve our collaborative cancer reporting efforts