Updated on: November 21, 2016

Incorporate Coding Quality Audits into ICD-10 Preparations

Original story posted on: August 17, 2015

As organizations continue to search for ways to mitigate coder productivity loss following implementation of ICD-10, they also must consider methods to monitor and enhance coding accuracy. After all, productive coders are only effective when those coders assign accurate and complete codes. A low DNFB doesn’t denote coding compliance, nor does it imply that organizations are on the right track in terms of ICD-10 preparations.

Despite the best preparations, organizations likely will see a shift in accuracy rates once ICD-10 takes effect. Why? It will take coders time to get acclimated to working in a production environment.

Those who have had sufficient training and practice certainly will experience less of a shift; however, all coders undoubtedly will feel the effects. That’s why it’s important to establish a process for ICD-10 validation and auditing, particularly during the first few months after implementation.

Following are some tips to help coding managers and directors focus on implementing quality checks and audits:

1.  Strive to get back on track as soon as possible. Today, in ICD-9, coders strive for at least a 95-percent accuracy rate. Although this should be the goal in ICD-10 as well, managers and directors must understand that achieving this goal may take time. However, every organization should target a 95-percent accuracy rate (or better) as soon as possible to mitigate ongoing denials. Dual coding helps identify coders who may be struggling with certain aspects of ICD-10. It also helps identify larger trends (e.g., a root operation with which all coders struggle).

2.  Identify a facility ICD-10 lead who can research ICD-10 questions as they arise. Although Coding Clinic has published ICD-10 guidance exclusively since the first quarter of 2014, many questions pertaining to specific scenarios continue to surface. An ICD-10 lead can compile these questions, submit them to AHA’s Coding Clinic Advisor, and disseminate information once it is received. Many organizations are combining this role with that of ICD-10 auditor. Consider someone who is an American Health Information Management Association (AHIMA)-approved ICD-10 trainer and who has worked with ICD-10 directly for at least one year. To maximize efficacy, this individual should not be involved in coding active records. Rather, he or she should be able to focus entirely on coding education and auditing.

3.  Establish a plan for how to handle gray areas. Although organizations can submit questions to Coding Clinic, it often takes time to receive a response. It may not be realistic to suspend claims indefinitely while waiting for a response. Determine how you will maintain these cases in a separate queue and how you will bill them if a timely response from Coding Clinic is not possible. In lieu of formal guidance, consider the following:

    1. Ask for guidance from clinical documentation improvement (CDI) specialists or physician champions.
    2. Reach out to state and regional health information management (HIM) associations to inquire how other organizations are handling the scenario.
    3. Ask for input from coding vendors.
    4. Discuss scenarios during weekly coding department meetings.

4.  Make internal coding guidelines a dynamic document. When issues surface, keep track of how the department ultimately decides to handle them. What is the consensus until formal guidance is received? Document this information and update it when more formal information is received. Be sure to include the specific date on which formal guidance is received, and disseminate this information immediately. Doing so ensures that all coders will code consistently, and it also provides an audit trail should denials occur. Organizations may be able to rebill these cases. It’s helpful to be able to quickly identify a specific date on which the coding process changed.

5.  Prioritize cases for quality reviews. Most organizations do not have the time or resources to perform a 100-percent manual review of all cases in ICD-10. Instead, focus on the following:

    1. Current cases that require a manual review in ICD-9 (e.g., auditor targets, payor targets, DRGs that are denied frequently). Some hospitals may use editing/validation software to identify cases that are more prone to error.
    2. High-volume cases.
    3. DRGs or procedures with which coders have struggled during dual coding (and for which refresher training has been provided).

 Other tips

When it comes to accuracy and quality, think outside the box. Consider the following other ways in which MRA’s clients are working diligently and collaboratively to ensure quality coding:

  • Dividing the coding auditor/validation role among various hospitals in a multi-hospital system. This individual splits his or her time among various hospitals, each of which contributes to the cost of supporting this role.
  • Hiring a temporary coding auditor/validator for an 18-month period post-implementation to help the organization get through the initial transition period.
  • Working with an outsourcing company to secure assistance with quality audits before and after implementation. When pursuing this route, be sure to inquire about consultants’ training and direct hands-on experience with ICD-10. It’s easy to understand ICD-10 concepts; however, being able to apply those concepts to actual medical records requires an entirely different level of expertise.

Remember, when it comes to ICD-10 coding, accuracy and quality must go hand in hand with productivity.


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.
Cathie Wilde, RHIA, CCS

Cathie Wilde, RHIA, CCS, is the director of coding services for MRA. Ms. Wilde has been active in the healthcare industry for more than 30 years. Her previous positions have included assistant director of HIM, DRG coordinator at the Massachusetts Hospital Association, and DRG validator at Blue Cross Blue Shield. She has extensive experience in ICD-9-CM and CPT coding, auditing, data analysis, development and testing of coding products, specialized reporting, and in-service training. As director she is responsible for overseeing the coding division, providing the strategic direction of MRA as a local industry leader of quality coding, auditing, and denial management services. Ms. Wilde is an American Health Information Management Association (AHIMA)-approved ICD-10-CM/PCS trainer.

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