May 8, 2015

Think “Process Improvement” to Mitigate Coder Productivity Loss in ICD-10

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Everyone is anxious about how ICD-10 may affect coding productivity and quality. Although we won’t have specific answers until we’re in the thick of things after Oct. 1, there are plenty of strategies that health information management (HIM) directors and managers can use today to mitigate potential problems. Many of these strategies pertain to process improvement – that is, examining workflow more closely to identify the hurdles that slow down coders. Doing this helps coders feel more confident in preparing for ICD-10 while also easing the burden of ICD-9.

Consider the following processes and tasks that may require some fine-tuning between now and the implementation deadline:

1. Non-coding responsibilities. How much time do coders spend performing miscellaneous abstracting and other non-coding or administrative tasks? For example, must coders abstract and code blood transfusions? Must coders be responsible for listing the type of anesthesia? Examine whether this information is already collected in another hospital department – or even whether it’s still relevant to collect the information at all. Can you reassign this task to someone else? When a discharge disposition must be verified, should coders be the ones who perform this task, which often involves tracking down the answer with a case manager, or can you assign the follow-up and verification to a data clerk?

2. Overall coding efficiency. Although computer-assisted coding (CAC) can be of great help to coders, not every organization has had the luxury of being able to implement this technology. However, there are many other ways in which directors and managers can increase efficiency in the absence of CAC.

First, ensure that all coders have access to online coding tools, such as medical terminology references, anatomy and physiology resources, Coding Clinic, and CPT Assistant. The department should have at least one hard copy of both an ICD-10-CM and ICD-10-PCS book. Make sure they have these coding resources at their fingertips so they don’t spend valuable coding time tracking down information.

Second, perform documentation gap analysis to identify areas of improvement for ICD-10. If coders have the information they need, coding efficiency will increase dramatically. Some of this information may not even pertain to physician documentation specifically. For example, ICD-10-PCS demands device information for certain procedures. Do operative reports include device stickers that denote this? If not, how can you ensure that these details are captured? If your facility uses certain devices, work with the materials department to identify appropriate coding for each device so the procedures can be coded consistently.

Third, ensure that coders can find information in the electronic health record (EHR). Coders often complain that information is not easily accessible in the electronic record. This could be due to poor design, or it could be the result of copy-and-paste documentation. Either way, work with your EHR vendor to address the problem. For example, consider separating the nursing progress notes from the physician progress notes. Also consider separating out ancillary reports with specific tabs for labs, pathology, and microbiology. In general, ask these questions: How can the vendor ensure that the record supports the coding function? How can the vendor help address the problem of cloned documentation? Coders (and providers) should not need to spend time rereading repetitive documentation. Should you consider providing physician education about how this documentation can slow coders down and also jeopardize the quality of clinical care?

3. Queries. The query process must be as efficient as possible to accommodate a potential increase in volume with ICD-10 implementation. Where will bottlenecks occur? HIM directors must ensure an efficient process as well as work closely with clinical documentation improvement (CDI) to reduce the need for queries in general. Also, determine who tracks queries and how. Can you streamline the process? Talk with physicians to better understand their preferences. What works well and what doesn’t? Which physicians have a poor response rate? Coders shouldn’t get bogged down in following up with physicians. This cuts into coding time and it may also irritate physicians. A designated data clerk can provide assistance in this area as well.

4. Ensuring staff coverage. How will you ensure that you have enough coders to maintain productivity levels before, during, and after the transition? Develop a schedule for the two months prior to implementation as well as the two months after implementation to address any planned vacations. Organizations need to have all hands on deck to make this transition successful. Outsourced coding vendors can help ease the burden, but again, proper planning is key.

5. Preparing for an increase in coding questions. Coders are accustomed to helping one another tackle tricky coding scenarios. However, until Coding Clinic publishes more comprehensive guidance, complicated scenarios may continue to play out in ICD-10. Even with more guidance from Coding Clinic, questions will remain. Coding managers’ tasks should be streamlined so they can receive and review questions as they arise. HIM departments need a clear process for handling these questions so coders don’t become overwhelmed. Some organizations may opt to hire a coding educator who can serve as an internal resource. This individual can receive questions, research them, send them to Coding Clinic, and then perform follow-up education. Some departments may be able to appoint someone internally in this role; however, doing so may require additional staff to compensate for removing that individual from the coding work queue. Organizations, particularly large teaching facilities, also may want to consider assigning certain coders to specialize in more complicated, high-volume cases such as interventional radiology and major cardiovascular procedures. Provide these coders with more intense and targeted training in these areas.

Ask coders what they want/need.

Another helpful strategy is to simply survey your staff about what works well and where coders would like to see improvements. To improve processes, directors and managers first need to understand those processes. Some directors and managers may not even be aware of all of the small tasks that coders perform on a daily basis. Others may be unaware of ongoing problems. For example, does a particular remote coder constantly have Internet connectivity issues? If so, work with that coder to address the problem. Ensure that the IT department understands the seriousness of the problem and how it could affect productivity and revenue. The IT department should give priority to coding-related projects and problems.

Ask coders whether they feel comfortable with ICD-10. Have you provided enough practice time and education? Where do coders continue to feel uncertain? Can you provided targeted education or bring in an additional trainer to help boost confidence? All of these things will contribute to your success.

 

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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