September 10, 2013

To Dual Code or Not to Dual Code – That is the Question

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Many organizations have a plan associated with their commitment to perform dual coding to achieve the widely publicized benefits outlined below. Although there is not an official dual-coding survey that examines the frequency, duration, scope, methodology and outcomes associated with the overall provider plans and experiences, it is clear from the industry buzz that gaining an understanding of the risks, benefits and alternatives is essential for informed decision-making – and to enable any healthcare organization to go into this process with its eyes wide open.

What is Dual Coding?

Dual coding is a practice widely defined as natively assigning both ICD-9-CM and ICD-10-PCS codes to a record during the same coding session; this activity can be performed by two separate coders to capture both code sets. Doing so is an effective method of obtaining accurate data in order to enable comparisons across code sets, allow for prediction of reimbursement discrepancies, and provide better case mix index comparisons.

Some organizations use mapping tools to convert ICD-9 to ICD-10, and others are re-coding claims without reviewing the original records. There is risk in this approach because mapping has about a 10 percent discrepancy rate, necessitating review of the medical record. Re-coding claims without reviewing the relevant documentation can result in significant data quality deficiencies associated with failing to capture co-morbidities, such as post-operative hemorrhages or infections. Such conditions, if not originally coded, will not be recorded properly following conversion to ICD-10.

What are the Benefits?

Dual coding can help hospitals prepare for ICD-10 and mitigate the risk of denied claims. Dual coding is also the first step in end-to-end testing for ICD-10, and it helps generate solid, comparative data for forecasting. Also, dual coding helps organizations assess coder productivity, clinical documentation improvement (CDI) specialist workloads, staffing requirements, and operational budgeting.

From a clinical standpoint, dual coding additionally helps in identifying gaps in documentation, fine-tuning CDI specialist activities, and updating clinical content in the electronic medical record. With the increased number and specificity of codes under ICD-10, physicians must be more precise in their patient encounter documentation in order to enable coders to choose the correct codes for optimal reimbursement. Finally, ensuring meaningful payor collaboration to determine the financial impacts of the transition to ICD-10, along with providing data from dual coding for testing of all systems that use the code sets, is an essential factor.

What are the Risks?

The cost of labor to code in ICD-10 is a concern fueled by budgetary constraints, coder shortages, and training and technology schedules. Organizations can mitigate these concerns and control costs by focusing on high-impact cases identified through ICD-10 gap/impact analysis.

What are the Alternatives?

As outlined above, using a mapping tool to convert ICD-9 to ICD-10 (or vice versa) provides an associated discrepancy rate of 10 percent, necessitating review of the medical record. There are some technology options that purport to allow a coder to use a single logic pathway to derive ICD-10 and ICD-9 codes simultaneously. Computer-assisted coding (CAC) also can mitigate some of the productivity decreases associated with dual coding.

Defining the Scope

Many organizations are limiting the scope of their dual coding to high-impact or high-volume areas of concern and enabling coders to practice an hour or two a day in order to minimize labor costs. Other organizations are using predictive analytics to proactively select cases for which coding or documentation issues will impact reimbursement or data integrity adversely. Some organizations have been able to dedicate a coder to this activity or utilize contract labor in this capacity.

 


 

Timing

Some organizations are delaying their dual coding-processes until they offset the labor impact with technology, such as a CAC application. Other organizations still are awaiting vendor fixes to enable dual abstraction in both ICD-9 and ICD-10. The majority of hospitals are going live with dual coding in the spring of 2014 (April, specifically) to ensure the availability of a full six months to refine their approach, workflows, systems and payor strategies.

Conclusion

Based on industry discussion, there are still a fair number of organizations on the fence regarding the need to perform dual coding prior to the transition to ICD-10 (or whose budgets are insufficient to cover projected productivity gaps). The risks and benefits outlined above reinforce the need to examine your current and future states of coding and documentation practices in order to mitigate the impact of reimbursement, denial and documentation integrity challenges. Provider leadership also must drive home the critical nature of performing dual coding as a basis for testing the effectiveness of transitional strategies associated with all facets of the ICD-10 lifecycle leading up to implementation. Failure to try the new workflow and processes on for size would be analogous to flying a new plane without a safe, simulated environment, leading to a test flight with refinements made along the way.

How are your coders going to receive comprehensive feedback regarding how they are doing? How will your American Health Information Management Association (AHIMA)-approved ICD-10 trainers gain knowledge associated with the effectiveness of the educational strategy being leveraged? How will you obtain a sufficient test bed of coded claims to feed your test scripts and to participate in integrated testing? How will you be able to ensure sufficient claims information to test reimbursement assumptions, payor contract modeling scenarios, and DRG reimbursement assumptions?

It is not too late to begin to discuss and develop a plan to achieve the benefits of dual coding. This is not an area to skimp on if your budget is tight and your resources are light. Identify some creative approaches to ensure an adequate sampling of cases. Put more effort into strategic sampling to obtain the biggest bang for your buck.

Next month I will focus on some areas to concentrate on to facilitate an optimal strategy and approach.

About the Author

Cassi Birnbaum, MS, RHIA, FAHIMA, CPHQ, is vice president of health information management for Peak Health Solutions, specializing in providing remote coding, auditing, data collection and analysis, clinical documentation improvement, ICD-10 transition, and HIM resource planning services nationwide. For the last 15 years, Birnbaum was the director of health information and privacy officer at Rady Children’s Hospital in San Diego, Calif.

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Cassi Birnbaum, MS, RHIA, CPHQ

Cassi Birnbaum, MS, RHIA, FAHIMA, CPHQ, is vice president of health information management for Peak Health Solutions, specializing in providing remote coding, auditing, data collection and analysis, clinical documentation improvement, ICD-10 transition, and HIM resource planning services nationwide. For the last 15 years, Birnbaum was the director of health information and privacy officer at Rady Children’s Hospital in San Diego, Calif.