The Value of a Certified Coder and CDI in our Practices

Original story posted on: September 24, 2018
With good collaboration and the right team members, continual improvements are attainable.

Recently I have been engaged in a project of continual improvement in our clinics, and as chief compliance officer, I am continually looking for ways we can stay compliant, deliver excellent healthcare, and fix revenue leaks.

We audit our physicians on a quarterly basis until they reach our pre-assigned accuracy rates, then they are audited on an annual basis. After each audit, one of our certified coders trains the physician on their results, along with their techs or scribes. The education is tailored specifically for each team.

While the education and audits were helping us retroactively address problems and potential improvements, there was nothing in place to help us proactively reach those same goals. Even though we were tracking significant progress, the results were slower due to the process.

It was then that we began engaging in a formal coding scrubbing program. Using certified coders, we evaluated documentation prior to the claims being submitted. The results have been phenomenal.

In our model, we do not have the coders review every single claim; this is cost-prohibitive and can slow down the overall process. We know what we do well, and we allow those claims to go through based on the physician coding choices. Instead, we use a targeted method. In our model, we scrub for the following:
  • Any risks identified during audits
  • All surgical claims
  • All claims that include diagnostic testing
  • High-cost injectables

Our main purpose for the program is to remain compliant while making sure we are protected where we have identified the most risks. We are able to find thousands of dollars in missing charges for most providers each week. The program is fluid, and it changes as new risks and opportunities are identified.

The most important part is the continual education and engagement of the entire team. Without great collaboration, success is limited.

In addition to the missing charges, we have found many areas ripe for improvement that we were able to act on quickly rather than retroactively at audit time. In addition, we were able to address noncompliant behaviors in real time, allowing us to become a very compliant organization. For our practices, we were able to identify:
  • Wrong levels chosen
  • Missing interpretation and reports
  • Issues with the setup of our new electronic medical record (EMR)
  • Injections billed at wrong units or missed
  • Not all surgical procedures being captured

The continual focus on clinical documentation improvement (CDI), with the education and the addition of new coding scrubbers, has allowed us to generate over a million dollars in one year in one of our larger clinics that has 46 providers. That was after fixing miscoding identified on coding scrubbing.

The teamwork being exhibited is amazing. When a problem or improvement area is identified, the team works directly with the providers. The providers are much more engaged, and love knowing what is going on. In addition, by engaging their ancillary staff, everyone understands their role in the documentation journey to excellent patient care.

For those practices that don’t feel they can afford a certified coder, this model demonstrates that you really cannot afford to go without one. You must be sure to be consistent in your processes, and education is a must. Teams must be engaged and willing to change for the better. With good collaboration and the right team members, you can see continual improvements.

It’s also important to note that while we have seen amazing results in revenue, that cannot be the driving focus of the program; you must address the overall needs of the practice, and involve compliance in your improvement efforts.

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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.

Rhonda Buckholtz is the vice president of practice optimization for Eye Care Leaders. She has more than 25 years of experience in healthcare, working in the management, reimbursement, billing, and coding sectors, in addition to being an instructor. She is a past co-chair for the WEDI ICD-10 Implementation Workgroup, Advanced Payment Models Workgroup and has provided testimony ongoing for ICD-10 and standardization of data for NCVHS. Rhonda spends her time on practice optimization for Eye Care Leaders by providing transformational services and revenue integrity for Ophthalmology practices. She was instrumental in developing the Certified Ophthalmology Professional Coder (COPC) exam and curriculum for the AAPC. Rhonda is a member of the ICD10monitor editorial board and makes frequent appearances on Talk Ten Tuesdays.

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