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Claims & Coding: Roundup

Education, training and support are keys to avoiding coding errors

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Steve Sabino, president, t DST Health Solutions

Although payers face challenges in transitioning to ICD-10, they can overcome them through education, training and support, scenario- based thinking and investment in newly available technologies. Providers must learn how to select from among an escalating number of increasingly granular diagnoses to receive accurate, timely reimbursement. Because ICD-9 offers three codes for angioplasty and ICD-10 offers

1,098, cardiologists, for example, must focus on their most frequently used codes. But each physician, no matter what his or her specialty, must work from an expanded set of clinical notes to isolate the most appropriate diagnoses and express clinical intent. By reviewing potential scenarios, payers can ensure they won’t pay $16,000 for a service they previously paid only $10,000 for under ICD-9. GEMs are already guiding payers on appropriate

provider reimbursement. As an alternative, payers can invest in technologies that identify dominant ICD-9 codes based on claims analysis, as well as those at greatest risk for improper interpretation within ICD- 10. Payers should use this time of transition to evaluate how the structures and processes of ICD-9 compare with the purpose, design and anticipated results of ICD-10.

Create an acceptance test that defi nes the expected outcome

In software, test-driven development (TDD) is among the most reliable rapid development methodologies. This strategy is easily adapted to help in the transition to ICD- 10 and can help to significantly reduce coding errors. While many ICD-9 /ICD-10 codes map cleanly, the combination of ambiguous mappings and reimbursement types is more likely to result in errors. For these scenarios, create an acceptance test that defi nes your expected reimbursement outcome. In order to pass this test it will take a combination of fi nding the correct mapping and working with internal and external stakeholders to have results that can be compared to the test. What’s noticeably different about this approach is that it makes the time-consuming planning and analysis project phase more outcome-centric. A project team has the least amount of experience at the very beginning of a conversion project and yet ironically this is precisely when they are expected to plot out a successful road map. A TDD approach focuses the project team solely on the intended outcome and quickly immerses them in the more complex implementation component of the project. It further limits the scope to bare minimum requirements needed to achieve success, circumventing debilitating analysis-paralysis that often occurs during signifi cant large-scale change.

Sal Novin, CEO,

Healthcare Productivity Automation

Education will remove barriers to ICD-10 success The need for ICD-10 training


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Deborah Neville, director of revenue cycle, coding and compliance, Elsevier

is urgent, but providers may not be up to speed. Seventy-one percent of providers have formed an ICD-10 task force, although only half have invested in staff training, according to a survey of U.S. hospitals by J. A. Thomas & Associates. Three-quarters of respondents point to physician buy- in and training as the most signifi cant challenge, with slightly more than 70 percent citing a need for in-house and

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external ICD-10 program training. Providers can ease ICD-10 education by following these steps: • Identify the unique learning needs of stakeholders.

14 July 2011

Conduct focus groups, surveys and meetings to discern healthcare professionals’ needs, priorities and reservations.

• Make education and training an ongoing process and daily event.

• Monitor coding accuracy and productivity. Develop tracking mechanisms to identify professionals’ coding speed, efficiency and accuracy. Develop training experiences to fi ll productivity gaps.

• Engage in open communication with payers. Evaluate payer readiness.

• Estimate the impact of ICD-10. Conduct an evaluation of your case mix and top MS-DRG payments and then map to ICD-10.

• Identify workfl ow improvements.


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