By Mike Evans, RHIA, CCS, vice president of coding and compliance at In Record Time, Inc.
Over the last decade, it has become more and more challenging to maintain coding efficiency. In addition to ensuring accurate code assignment, today’s coders must:
Review documentation more thoroughly to mitigate auditor scrutiny
Know where and how to find information in the electronic health record
Be able to sift through copy and paste documentation
Ensure clinical validation
Query when documentation is unclear or ambiguous
Some coders also perform abstraction, physician education, and more. In the midst of all of this, coders must turn their attention toward ICD-10 to ensure accuracy and specificity.
As HIM directors and managers continue to prepare for ICD-10, it’s important to re-evaluate coding workflow and processes to ensure maximum efficiency. Current inefficiencies will become magnified in ICD-10, leading to a domino effect of delayed reimbursement and denials that no organization can afford. Following are some tips that managers can use to streamline coding efficiency today and heading into ICD-10.
Tip #1: Provide comprehensive ICD-10 coder training. This truly cannot be emphasized enough. Coder training will be one of the most significant determinants of efficiency and productivity in ICD-10. Even if coders have already received formal training, ensure that they continue to receive refresher training as well as adequate time to practice dual coding between now and October 1, 2015.
Tip #2: Ensure sufficient coverage. Many organizations are hiring additional coders or contracting with outsource vendors to provide coverage before, during, and after the transition to ICD-10. Managers may also want to consider expanding the five-day workweek to include evenings and/or weekends. Coding backlogs can easily occur when coders only work Monday through Friday. This backlog can increase exponentially when ICD-10 takes effect. To ensure a smooth cash flow, consider a rotating schedule for overtime work or hiring an outsource vendor to handle cases after normal business hours and on weekends. Even focusing on ER records only can make a big difference.
Tip #3: Consider removing non-coding duties. Managers may be able to increase coder efficiency by allowing coders to focus solely on coding. Doing so would absolve them of responsibilities such as CDI, answering the telephone, abstracting, and answering questions from patients. Each organization must determine what—if any—responsibilities can be reassigned to other individuals.
Tip #4: Ensure that coders know when to report symptom codes. Outpatient coders can become particularly bogged down when reporting signs and symptoms that have little clinical pertinence to the case and that don’t pertain at all to medical necessity. For example, coders may report nausea when the patient has acute cholecystitis. In the outpatient setting, coders must code to the highest degree of specificity documented; however, it’s not appropriate to code signs and symptoms that are related to the underlying diagnosis.
Tip #5: Consider implementing computer-assisted coding (CAC). CAC can potentially be a game changer in terms of coding efficiency on the inpatient side. However, implementation of CAC is a long process that must include considerable oversight. CAC technology is only as effective as the documentation on which it’s based. Coders must continue to review and audit any codes that the CAC technology suggests.
Tip #6: Hire an external vendor to perform a workflow assessment. Such an assessment includes looking at the progression of documentation and processes that occur beginning with the moment the patient enters the facility to the moment he or she is discharged.
Tip #7: Take a close look at documentation. Coding efficiency and productivity are directly linked to the quality of physician documentation. If documentation is subpar, coders’ efficiency—and perhaps accuracy—will be compromised. Consider the following questions:
Do physicians document all possible CC and MCC conditions to reflect patient severity? If not, what CC and MCC conditions are typically lacking? Do physicians need additional education? How can the organization convey the importance of these conditions in terms of reimbursement as well as overall clinical care?
Can the organization capitalize on dictation when possible? Although there seems to be a general push toward online documentation in which physicians enter information into templates via the EHR, I’ve observed that physicians are more likely to provide rich clinical details when they are dictating. These details and observations are critical for coding purposes. If physicians enter information into templates, does it include all of the data necessary for coding? If not, can physicians rely on dictation in some instances? In an ideal world, physicians would have the option of dictating or using a template in real time depending on the clinical scenario. Some organizations have even begun to use scribes (i.e., medical students or nursing staff) who dictate the entire clinical experience. This works particularly well in the ED setting. The goal is to provide flexibility while maintaining clinical integrity within the documentation.
What is the quality of the discharge summary? The discharge summary is particularly important for coding purposes, as some conditions cannot be coded unless a physician validates them in the discharge summary. However, the quality of a discharge summary often varies by organization or even individual physician. Coders are more efficient when the discharge summary is accurate and detailed, providing a thorough glimpse into the entirety of the patient’s stay.
Tip #8: Implement an electronic document management system (EDMS). Organizations that continue to scan records partially or entirely face many challenges in terms of coding efficiencies. Coders often struggle with simply finding the information they need for coding purposes. I’m aware of at least one hospital in which coders must scan through 8-10 pages of information before they find clinical data. An EDMS can help coders index and retrieve information more easily. This will be incredibly valuable heading into ICD-10.
Tip #9: Talk to the coders. By talking openly with coding staff members, managers can identify frustrations and other concerns that could take a toll on productivity. Do coders feel supported by the larger administration? Do technology challenges slow coders down? Can coders rely on clear and updated policies and procedures? Remember that happy coders are efficient coders.