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 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.

 By Mike Evans, RHIA, CCS, vice president of coding and compliance at In Record Time, Inc.

 Coders are among the busiest employees in any hospital nationwide. However, they must make time to practice using ICD-10 even despite strict productivity requirements. In particular, practicing ICD-10-PCS will be critical as the industry heads into 2015. ICD-10-PCS is far more complex than the ICD-9-CM procedure coding system to which today’s inpatient coders are accustomed. In PCS, coders must be able to complete a seven digit alphanumeric formula. If they’re unable to assign even one character in the formula, they’ll be unable to assign the entire code.

 Experts agree that without critical details in the documentation, coders may default to non-specific codes. This is certainly not the intent of the more specific PCS coding system. It’s in coders’ best interests to practice using PCS as much as possible between now and October 1, 2015.

 Where should coders focus their ICD-10-PCS training efforts? One of the most difficult aspects of ICD-10-PCS may be assignment of the root operation. For this reason, coders may want to devote significant time in this area. Identifying an improper root operation can lead coders down a completely incorrect path to code assignment. Incorrect code assignment ultimately jeopardizes both reimbursement and data integrity.

 Coders should also spend the majority of their time practicing more complex cases, such as CABG procedures, OB/GYN procedures, orthopedic surgeries, and neurosurgical cases. These procedures are the ones that will likely cause bottlenecks in terms of productivity. Some of these procedures may even require more than one PCS code to fully capture the entire operation the physician performs.

 Another approach is to focus on high-volume procedures; however, keep in mind that these procedures may not be the most complex and therefore time-consuming.

 Once coders have mastered root operation definitions, focus on whether coders can translate clinical terminology to a specific PCS operation. Physicians are not expected to make this translation. The 2015 ICD-10-PCS Official Guidelines for Coding and Reporting state the following:

 It is the coder’s responsibility to determine what the documentation in the medical record equates to in the PCS definitions. The physician is not expected to use the terms used in PCS code descriptions, nor is the coder required to query the physician when the correlation between the documentation and the defined PCS terms is clear.

How can coders work with medical staff to practice ICD-10-PCS? Ask medical staff members to identify the top 10 most complex procedures that they perform. Also inquire whether physicians would be willing to walk coders through the steps they take during each of these procedures. This can help coders visualize the procedure when coding.

 Physicians should have already begun to document the additional details necessary for ICD-10-PCS, such as anatomical specificity and laterality. When physicians document these details, not only are they practicing good habits, but they’re also making records more helpful for coders who will use de-identified versions for practice purposes. If these details are missing from the record, coders have no choice but to assign an unspecified code.

Why is it important to audit for quality? Even when coders practice ICD-10-PCS on a daily basis, they’re still bound to make mistakes. Quality monitoring is critical, both now and once the new coding system takes effect. As coders practice using PCS, ensure that a manager verifies their work. When questions or discrepancies arise, address these topics during coding staff meetings. Develop internal coding guidelines to identify how coders will tackle certain procedures in lieu of updated Coding Clinic references.

 How can organizations make coder training in general a priority? Unfortunately, training and education budgets are often among the first to be reduced or cut entirely when organizations seek to reduce operating costs. Coding managers and HIM directors must work with hospital executives to explain the importance of ICD-10 and the role it plays in the overall financial viability for the organization. As was the case with the transition to DRGs in the early 1980s—as well as MS-DRGs in 2007—organizations likely won’t realize the true impact of ICD-10 until after implementation. We shouldn’t let history repeat itself. Investing in up-front coder training will mitigate the impact of the new coding system as much as possible.

By Mike Evans, RHIA, CCS, vice president of coding and compliance at In Record Time, Inc.

Internal coding audits have always been important. However, as third-party auditors continue to scrutinize documentation and coding practices, it’s more important than ever to ensure that these audits occur regularly and that they’re effective. All too often, internal auditors overlook critical aspects of the audit, resulting in skewed data that may not paint a clear picture of trends and patterns. Even when conducted properly, audits may not yield results that are truly useful to the organization.

 Following are some of the most common mistakes that internal coding managers and/or HIM directors make when conducting internal coding audits.

 1. Audits are too narrow. Internal managers sometimes approach an audit with an agenda to increase CC or MCC capture. When organizations narrow their focus in this way, they may miss out on other problems within the documentation or coding. Instead, organizations should focus audits on documentation integrity—not simply identifying missing elements that would have increased reimbursement. Ideally, audits should ensure the following:

 ·         Multiple CC and MCC capture, when appropriate. Capturing only one single CC or MCC may not be sufficient in terms of ensuring a correct severity of illness (SOI) or risk of mortality (ROM). SOI and ROM both affect the observed vs. expected death rate—an important indicator of the quality of care provided.

·         Correct POA indicator assignment. This plays an important role in patient safety indicator (PSI) scores. An inflated POA indicator rate could inflate the PSI rate as well.

·         Compliant complication reporting. Physicians are hesitant to label complications as such; however, organizations need to encourage physicians to document complications when they occur. Reiterate to physicians that complications that occur intra-operatively are generally not the fault of the physician, but rather they’re due to a problem with the patient’s own health circumstances.

 2. Audits don’t look beyond the organization’s own walls. One of the biggest mistakes that organizations make is not looking at how their data compares with other facilities in the state, region, or nationwide. Knowing how your organization compares with its peers is important because patients have access to this data that is reported on an aggregate level to various state health agencies. Sites such as Physician Compare and Hospital Compare make it very easy for consumers to shop around for the best quality care. Organizations need to know how they stack up against other facilities so they can take steps to improve data quality and public perception.

 Knowing how the organization compares with others is also important in terms of gauging vulnerability for external audits. The Program for Evaluating Payment Patterns Electronic Report (PEPPER) is a helpful resource that provides hospital-specific data statistics for improper payment targets. Organizations can use PEPPER to compare their data other hospitals or facilities in the state, specific Medicare Administrative Contractor (MAC) jurisdiction and the nation.

3. Auditors don’t look for the story behind the numbers. Internal auditors may not look for the root cause of audit results. Instead, they must simply assume that the results are based on incorrect coding. However, the trigger may be something process-related and/or entirely unrelated to coding. For example, if the organization’s procedure is to require coders to code without the discharge summary, this might affect a coder’s ability to capture the principal diagnosis correctly. Consider a transient ischemic attack (TIA). When a physician documents both a TIA and a cardiovascular accident (CVA) throughout the record—but doesn’t rule out the CVA until the discharge summary—how can the coder truly know what proper principal diagnosis to report?

Another example relates to septicemia vs. urinary tract infection (UTI). Are coders required to query when the record is unclear? Are they given sufficient time to do so? If not, unclear documentation could lead to an unusually high rate of septicemia that could appear quite alarming during an audit.

Other root causes could relate to insufficient physician documentation, EHR glitches, etc.

 4. Auditors don’t use updated resources. It’s a full-time job to keep up with ever-changing audit targets and requirements. However, using outdated resources and references can provide skewed audit results. Be sure to use updated coding guidelines and updated insurer policies. The Recovery Auditor FY2013 Report to Congress and FY 2015 OIG Work Plan are also good references in terms of structuring an audit and keeping updated on the latest targets.

 5. No follow-up education is provided. After the conclusion of an internal audit, provide audit results to coders, physician advisors, and CDI specialists. Include a physician advisor when providing education to physicians, as they generally respond more positively when receiving information from a peer.

 6. Organizations don’t perform follow-up audits. Perform an audit six months after concluding the original audit. This ensures the efficacy of any steps taken to rectify problems identified during the first audit.

 How an external vendor can help

External coding vendors provide an unbiased look at an organization’s data. These auditors don’t have an agenda, and they also have no connection to the data. They often provide the impartial analysis that organizations need.

 In addition, external vendors can perform the type of in-depth data analysis necessary to compare an organization’s performance (i.e., its DRG and APC mix) with similar facilities on a city, state, regional, or national level. Many external auditors work with clients nationwide, meaning they bring a wealth of knowledge and experience to the table. Organizations benefit from this bird’s-eye view of what’s going on in the industry in terms of third-party auditor trends.

By Mike Evans, RHIA, CCS, vice president of coding and compliance at In Record Time, Inc.

Now that ICD-10 has been delayed until October 1, 2015, many organizations are left wondering how to make the most of this interim time. Our experience has been that as many as 50%-60% of hospitals slowed their ICD-10 efforts when the delay was announced. Although many organizations have chosen to put ICD-10 on a back burner for now, this isn’t necessarily the best solution, nor will it yield the most effective long-term results. Instead, HIM professionals—with the support of executive leadership—should devote as much time as possible to auditing, documentation improvement, and physician engagement.

 Consider the following strategies:

1.      Be transparent with physicians. Any major change can be scary and overwhelming, and the transition from ICD-9 to ICD-10 is no different. Even though they may not admit it, physicians could be among the most anxious about the new coding system because they know that their documentation will affect code assignment directly. Physicians may feel as though there simply aren’t enough minutes in the day to document some of the details required by ICD-10. To complicate matters, physicians face many other administrative challenges as well, such as Meaningful Use and quality reporting, both of which can affect their bottom line. Many of today’s physicians feel overburdened by a healthcare system in which third-party audits continue to mount, and additional regulatory requirements seem to grow annually.


The American Medical Association and various subspecialty organizations have voiced considerable opposition to ICD-10. Many physicians feel as though ICD-10 is being forced upon them rather than integrated into their daily workflow based upon their own input. This could be because many physicians weren’t involved in ICD-10 since the very beginning of its clinical modification for the United States. Although HIM professionals can’t rewrite history, they can talk openly with physicians, address their concerns, and most importantly, acknowledge their frustrations. Consider these tips:

·         Keep physicians in the loop. Send regular communications to medical staff about ICD-10 developments and news. Physicians will appreciate the outreach.

·         Focus on severity of illness (SOI). SOI has become incredibly important in terms of outcomes and data reporting. Every physician must understand how his or her documentation affects SOI scores because eventually, this information may affect one’s ability to participate with hospitals and insurers that will only want to contract with those who have the best quality outcomes. As Accountable Care Organizations continue to grow, only the best and brightest physicians will likely survive and thrive.

·         Listen. Simply listening to a physician voice his or her frustration about documentation requirements may go a long way in terms of changing his or her behavior. Let physicians know that the HIM department is available to answer questions and serve as a resource for physicians.


2.      Ensure time for dual coding. Although it may be difficult to justify dual coding indefinitely, coders need hands-on practice with ICD-10. This critical practice time coding records in both ICD-9 and ICD-10 allows coders to identify documentation gaps and educate physicians accordingly. Working with an outsource coding vendor can help create time for internal staff to dual code without interrupting cash flow. Start with high volume and/or high cost diagnoses and procedures to maximize efficiency.


3.      Identify a physician champion. HIM professionals know that it can be difficult at best to change physician behavior. If organizations haven’t already identified a physician champion, they should take the time provided by the delay to do so now. Consider these tips:

·         Choose an individual who is well-respected and an excellent communicator.

·         Look for someone who has excellent EHR skills and whose documentation can set an example for others.

·         If possible, identify one physician champion for medical cases and another for surgical cases. This avoids overburdening one individual, and it also helps send a message to the entire medical staff that the organization values their input enough to devote multiple resources to the effort.

4.      Work with your outsource vendor to identify additional strategies. Organizations that outsource all or a portion of their coding to a vendor should work closely with that vendor to identify opportunities for documentation improvement. A reputable vendor should perform ongoing quality reviews and audits and be willing to share that information with the organization.

ICD-10 delay causes challenges for HIM professionals:

Moving forward during uncertain times

 By Mike Evans, RHIA, CCS, vice president of coding and compliance at In Record Time, Inc.

When the ICD-10 delay was announced in April, most HIM professionals cringed at the thought of having to spend yet another year in limbo preparing for the transition. Working with an extended timeline has posed variety of challenges that physicians, legislators, and others in favor of a delay had not likely considered. Following are some of the most striking ones that affect HIM professionals directly.

Expensive coder refresher training. Many organizations had begun to provide coder training in anticipation of the original October 1, 2013 deadline and subsequent October 1, 2014 deadlines. Not only must these organizations now provide ongoing refresher training, but they’ll also need to consider careful strategies to retain coders in whom they’ve invested significant training dollars. Personnel changes complicate matters. As coders come and go (e.g., as coders find new jobs elsewhere, take time off, or retire), it becomes more difficult to maintain a secure set of knowledge.

Increased overall costs. In 2012, CMS estimated that a one-year delay could cost the industry as much as $6.6 billion. This statistic was reiterated in a letter from the Coalition for ICD-10—a constituency of organizations across the healthcare spectrum—to CMS dated April 11, 2014. According to a February 2012 Edifecs survey of industry reaction to the potential delay of ICD-10, 49% of respondents estimated that every year of delay would increase their required budget by 11%-25%. Thirty-seven percent estimated an increase of 26%-50%. Increased costs can largely be attributed to the need for ongoing training as well as outsource coding assistance so internal coders can gain hands-on experience with ICD-10. The longer the industry works with both ICD-9 and ICD-10, the greater the impact on overall productivity and cost.

The need to regain executive buy-in. HIM professionals may unfortunately bear the brunt of CFO frustration with ongoing ICD-10 costs. When the most recent delay was announced, many CFOs made the decision to drastically reduce ICD-10 budgets or even cut them entirely. Now, HIM professionals must restart facility-wide momentum even in the midst of ongoing skepticism. HIM professionals must re-engage executive leaders and medical staff in the ICD-10 effort. This will not be an easy task during a time when initiatives such as Meaningful Use, EHR implementation, hospital acquisitions and mergers, and a variety of other changes are vying for physician attention and hospital resources.

The need to re-engage physicians. It was difficult to engage physicians before the delay was announced. Now, it’s even more difficult to convince them that ICD-10 will, in fact, go live on October 1, 2015. Engaging physicians is an expensive and time-consuming effort that often requires the identification of physician champions, detailed documentation auditing, and personalized physician education sessions. Many physicians may be particularly resistant to learning the nuances of ICD-10 because they are unconvinced of its importance. This creates ongoing challenges for HIM professionals who must find creative ways to obtain physician buy-in.

Fear of the unknown. Experts agree that coder productivity could decline as much as 50% in ICD-10. The specific decrease will depend on a coder’s experience and education as well as system integration. Coders have been coding with this fear for several years. Some coders have even retired out of fear. Managing workers in an environment in which uncertainty and fear remain high has been—and will continue to be—challenging.

 As organizations continue to uncover challenges resulting from the ICD-10 delay, it’s important to consider these tips:

 ·         Provide ongoing refresher training for coders. This should include training in anatomy, physiology, pathophysiology, and ICD-10 guidelines. Allow coders to dual code regularly as well as attend state and local coding chapter meetings where they can receive cost-effective training. Also explore other free and low-cost training options.

·         Talk openly with coders so you can understand their short- and long-term employment plans.

·         Open the lines of communication between HIM and the C-suite. Set realistic expectations for budgeting that will allow for flexibility while also ensuring enough dollars for ongoing training.

·         Re-examine coder responsibilities. As the industry moves closer to ICD-10, coders must focus specifically on coding. If their duties also include abstracting or release of information, for example, consider reassigning those responsibilities to other staff members. This will help mitigate productivity loss and give coders more time to practice ICD-10.

·         Identify physician champions who can assist with physician re-engagement.

·         Consider outsourcing some or all of your coding. Maintaining an internal coding department may not be a cost effective solution at the present time.

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