Updated on: November 28, 2016

Focus on Quality Now and Productivity Will Follow

Original story posted on: March 14, 2016

We are five months into ICD-10 at this point. Many coders have plateaued or nearly plateaued as it pertains to productivity. So, if we have not already done so, we need to shift our focus from productivity and examine our coding quality. As I mentioned in my recent article “Coding Quality: It Affects More Than Claim Reimbursement,” a coding quality expectation of 94-96 percent is still valid.

We should be conducting coding compliance reviews more frequently than was done under ICD-9, until we’re certain that our staffs are achieving the quality expectation. Audits do not need to be performed solely by external auditors. We can conduct audits with our in-house coding staffers if they have the time to do them. 

Traditionally, organizations performed internal reviews and then, perhaps annually or so, depending on their findings, they would invite an external reviewer to conduct a coding accuracy review. This was done from both a compliance perspective (to demonstrate independence) as well as to see if items were overlooked during the internal audits.

With the coding and DRG changes that accompanied ICD-10 came the potential for errors that could be costly to an organization or trigger a red flag for an external compliance contractor or payer auditor down the road. An example of this may be the previously assumed relationship between diabetes and osteomyelitis in ICD-9. If the physician does not link the two conditions in the documentation today, and if these are the only two conditions, the osteomyelitis may be sequenced as a primary diagnosis and lead to a higher-paying DRG. Maybe that is not so bad! 

However, down the road, when those payer-related contractors review the charts and see a clinical indication implying that osteomyelitis was a manifestation of the diabetes, they will take the extra money back. This would be a prime example of where an internal reviewer or engaged external reviewer should recommend that the physician be queried to clarify the documentation. This finding also presents an opportunity to dialogue with the clinical documentation improvement (CDI) specialists about coaching physicians to link manifestations with the underlying conditions.

Additionally, the audits should not be limited to inpatient coding. Look at your ambulatory surgery coding as well as your pro-fee coding. Each of these has some ICD-10 coding associated with them, and they represent an opportunity to improve the specificity and accuracy of the coding. To this point, managed care contracts are becoming more aggressive with their penalties for coding errors, especially if the managed care organization is participating in a risk-based reimbursement program such as Medicare Advantage. I recently saw a clause in a Medicare Advantage contract with a hefty penalty for each encounter coded incorrectly.

Let me summarize with four focus areas for your first set of audits:

  1. Previously linked diagnoses. These ICD-9 linked codes that no longer exist in ICD-10 may lead to an overpayment. Use the audit to help you avoid being overpaid for something that should have clarified through a query or the CDI team.
  2. New coders. To specify, a coder who has never coded in ICD-9 or was a green coder in ICD-9 and is now launching a coding career in ICD-10 needs the extra attention and reinforcement of audit findings to hone their skills.
  3. Codes suggested by the computer-assisted coding (CAC) application that are routinely being accepted. Run a report from your CAC to find the frequency for accepting codes, by the code and by coder. It may reveal that coders are sacrificing quality for quantity to meet productivity levels or that they are assuming the CAC is always correct. Unfortunately, CAC technology is not at that level of exactness yet. We cannot assume that the CAC is always correct. On the plus side, this audit may validate the accuracy of your coders and the CAC you are using. It also may give you some items to refer back to your CAC vendor for them to adjust or “teach” their application.
  4. Comparison of ICD-9 DRG volumes to ICD-10 DRG volumes. Focus on those with a significant drop or increase in volume. This may be the result of a number of factors, but the ones I’d be watching for are:
  • DRG shifting;
  • Medical staff changes; and, of course,
  • Coding accuracy.

After you’ve focused on these four issues, you’ll certainly come up with other items to review. And remember, after March 12, if you find that an overpayment occurred, be sure to get it reported and refunded in accordance with the Centers for Medicare & Medicaid Services’ (CMS’s) new “report and refund” ruling.

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.
Rose T. Dunn, MBA, RHIA, CPA, FACHE, FHFMA, CHPS, AHIMA-approved ICD-10-CM/PCS Trainer

Rose T. Dunn, MBA, RHIA, CPA, FACHE, FHFMA, CHPS, is a past president of the American Health Information Management Association (AHIMA) and recipient of AHIMA’s distinguished member and legacy awards. She is chief operating officer of First Class Solutions, Inc., a healthcare consulting firm based in St. Louis, Mo. First Class Solutions, Inc. assists healthcare organizations with operational challenges in HIM, physician office documentation and coding, and other revenue cycle functions.

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