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Claims and Coding The drive to coding compliance

Three ways to ignite coding performance. By Cathy Brownfield, RHIA, CCS; and Alice Zentner, RHIA


Cathy Brownfi eld, RHIA, CCS, is VP of operations, TrustHCS. Alice Zentner, RHIA, is director of ICD-10 auditing and education, TrustHCS. For more information on TrustHCS solutions:

ealthGrades. Offi ce of the Inspector General. RAC. These are just a few of the eyes and ears of healthcare. Like a news reporter in search of a story, these industry watchdogs and others like them are peering over shoulders to uncover signs of poor patient care and fraudulent billing. Coded data is often the main source for their stories and lies at the center of their investigations. To cope, most organizations have implemented coding compliance along with clinical documentation improvement (CDI) programs. These programs work together to ensure revenue integrity, reduce ex- ternal investigations and miti- gate risk. By completing the coding and billing process right the fi rst time, organizations don’t waste time fi xing denied claims and can more easily re- duce operational costs. Finally, a strong compliance program

also ensures a facility is on track and equipped to handle the new requirements of the ICD-10 code set. If your organization’s coding and CDI programs are pro- ducing less than satisfactory results or coding errors continue to cause revenue loss, it’s time for a tune-up. There are three starting points for better coding compliance: unspecifi ed codes, high-cost/high-volume conditions and underperform- ing MS-DRGs (Medicare severity diagnosis related group).

The perils of unspecifi ed codes Vague, incomplete and non-specifi c documentation is one of the most common challenges facing clinical coders today. Unspecifi ed documentation leads to unspecifi ed codes. And unspecifi ed codes cause a myriad of revenue cycle problems, including heightened need for internal audits. Secondly, unspecifi ed codes draw down the case mix index (CMI) and negatively impact severity and risk scores such as those reported on HealthGrades. Recent audits comparing the same records coded in ICD-9 and ICD-10 demonstrate an increased number of unspeci-

24 July 2011

fi ed cases. This is because ICD-10 offers many more code choices and a deeper level of code granularity. Cases coded accurately in ICD-9 may lack the specifi city needed for ICD-10, resulting in an unspecifi ed MS-DRG. For example, asthma in ICD-10 requires documentation of mild, moderate or severe along with intermittent or per- sistent. Also, coding Crohn’s Disease requires much greater specifi city, including presence or absence of rectal bleeding, intestinal obstruction, fi stula, abscess or other complication. ICD-10 raises the bar on coding compliance and documen- tation. If the assignment of unspecifi ed codes continues in ICD-10, lower reimbursements will certainly be the result. To remedy the situation, providers should audit all cases of unspecifi ed coding within the current coding-compliance program. For each medical specialty, identify the areas where more comprehensive documentation will be required for ICD-10. Begin physician education programs now. “Lunch and learns,” pocket cards and other small reminders can supplement peer-to-peer training efforts.

CD 10 lti i

High cost and high volume are big concern ICD-9 has 59 codes for diabetes mellitus, while ICD-10 offers more than 200. And the term “uncontrolled diabetes,” one of the nation’s most common diagnoses, is not even mentioned in ICD-10. Instead, the exact manifestation of the uncontrolled diabetes must be documented and coded (e.g., diabetes with hyperglycemia). After decades of asking physicians to change how they document diabetes, the rules of the game are about to change. And diabetes is only one of the many high-volume conditions in healthcare. Organizations can begin today by identifying the top 20 conditions for volume and cost. Once identifi ed, cod- ing compliance and CDI teams should partner to conduct in-depth analysis of what documentation will be needed to support accurate ICD-10 coding for these diagnoses and procedures. Similar to the efforts mentioned above, physi- cian education and new knowledge levels for clinical coders will be required.


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