Updated on: November 21, 2016

Coder Assessments: Why they’re Critical in the Brave New World of ICD-10

By Paul Strafer, RHIA, CCS
Original story posted on: June 1, 2015

Coder productivity and quality have always been important, but with ICD-10, the stakes are higher. Insurers and auditors will be looking for the most specific ICD-10 codes to justify medical necessity for services rendered. Nonspecific codes will be denied and targeted by recovery contractors.

Coders undoubtedly will feel the added pressure of ensuring compliance. Organizations, in turn, must ensure a dynamic quality assurance process including ongoing audits and assessments to support this effort.

This article — the first in a two-part series — addresses why ongoing coder assessments are important as we venture into the uncharted territory of ICD-10. The second article will address the nuances of measuring and auditing coders in the ICD-10 environment.

Why Assessments are Necessary

Just as in ICD-9, coder assessments help managers do the following:

  • Collect formal data to supplement anecdotal data about coder performance.
  • Identify opportunities for clinical documentation improvement.
  • Identify areas of revenue risk.

In addition to these fundamental goals, assessing your coders for ICD-10 accuracy and performance — before and after implementation — as part of your coding compliance program is important to: 

  • Ensure a return on investment for costly coder training.
  • Pinpoint specific areas for improvement, including coder refresher training, to maximize training budgets.
  • Identify coder strengths and weaknesses to make informed decisions about specialization or appointing an ICD-10 auditor.

Pre-ICD-10 Coding Audits Difficult, but Worth It

Pre-ICD-10 coder assessments may be an organization’s most strategic asset to proactively safeguard revenue cycle stability. When conducting pre-ICD-10 assessments, managers must keep the following points in mind:

  • There will always be unpredictable variables. For example, coders could experience encoder problems, a rise in the volume of queries, or claims submission challenges, any of which could affect productivity and/or quality. These variables only will become apparent once ICD-10 is in place, and managers should plan accordingly. Ongoing workflow analyses are critical.
  • Chart “read time” impacts productivity scores. If coders code in ICD-10 first, it will take less time to code a chart a second time in ICD-9, as they’ve already read the chart and know the case. The same is true when coders code in ICD-9 first and then in ICD-10. Take this into consideration when reviewing productivity comparisons. Many experts agree that in general, productivity may take a 50-percent hit in ICD-10.
  • Manual assessments take time, so budget accordingly. Although manual assessments are better than nothing, they are extremely time-consuming. Managers must review each chart, provide immediate feedback to coders, and track performance over time. As an example, for one customer, managers that also wear other health information management (HIM) hats review only 60 cases (pre-ICD-10 coding reviews) per week across a team of 10 coders. Four to five days are required for this organization’s managers to score and analyze data results. A DRG coordinator or trainer solely dedicated to reviews would be expected to review more cases per week, or support a higher number of ICD-10 coders.

In a true ICD-10 production environment, the time required to assess, score, audit, and monitor coders will be multiplied by at least threefold. Many facilities will keep their coders on 100-percent review until they consistently reach quality expectations. It’s also recommended that coders code a wide variety of cases. One can safely assume that it will take reviewers approximately twice as long to review one case in ICD-10 compared to a similar case in ICD-9.

Also, it is expected that facilities may be forced to perform focused reviews on coders at least through January 2016 — and perhaps even up to 12 months post-ICD-10 implementation. Therefore, organizations must staff and budget for additional managers once ICD-10 goes live.

Looking ahead: Three Ingredients for Success

Managers must ensure that ICD-10 coder assessments incorporate three key ingredients to be effective, mitigate risk, and provide feedback for quality improvement.

  1. Real cases using real documentation. Hypothetical scenarios don’t paint an accurate picture of what coders will experience once ICD-10 is in place. Instead, use your facility’s actual records for all patient types.
  2. Immediate feedback. Feedback is more effective when it’s provided immediately upon completion of the assessment — when the cases are fresh in coders’ minds. Coders need access to a consistent answer key that provides real-time feedback explaining the correct answer, the rationale for that answer, and any supporting documentation.
  3. 3.    Dynamic and targeted education. Ideally, assessments will evolve to incorporate new and more difficult concepts as coders progress.

What’s your strategy to measure coder knowledge and mitigate ICD-10 risk?

About the Author

Paul Strafer is the Coding and Education Manager for H.I.M. On Call.

His experience includes ROI, DNFB management, and medical coding. Paul obtained both his RHIT and CCS certifications from the American Health Information Management Association (AHIMA) in 2013 and has recently obtained his RHIA credential. He also earned the 2014 Kathleen A. Frawley Memorial Scholarship through NJHIMA. Prior to joining H.I.M ON CALL, Mr. Strafer worked with several universities, including New York College of Technology, in developing curriculums and implementing full education programs for inpatient and outpatient coding, as well as AHIMA’s CCS certification prep. Paul is also a musician and music instructor and enjoys spending quality time with his wife and two young sons.

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Disclaimer: Every reasonable effort was made to ensure the accuracy of this information at the time it was published. However, due to the nature of industry changes over time we cannot guarantee its validity after the year it was published.

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