From a bird’s-eye view, the transition to ICD-10 has been a huge success with few technical glitches. However, it’s still early. Experts certainly don’t want to rain on anyone’s parade. However, they warn us that everyone must be realistic about the wave of ICD-10 denials that could hit throughout December and into the first quarter of 2016.  

The Risk of Rushing 

Data quality is still a concern, as organizations continue to push for a low discharged not final billed (DNFB) rate, even at the cost of accuracy. In some cases, coders are pressured to rush through coding complicated cases or even settle for unspecified codes just to get claims out the door. In worst-case scenarios, coders are so rushed that they’re technically performing at ICD-9 levels of productivity. Even though this may look good upon first glance, organizations must ask themselves: Is the accuracy rate as high as it was in ICD-9 (at least 95 percent) as well? If not, then what good is an ICD-9-level productivity rate? Given the likelihood of decreases in coding accuracy and increases in denials, it’s not very good at all. 

Coding Audits are Critical 

Now is the best time to carefully assess coder accuracy. Take this opportunity to establish an ongoing program for auditing and monitoring.

Budget time and resources for additional coding audits throughout 2016. Remember, much has changed. A strong audit program mitigates revenue risk, improves clinical documentation, and further educates coders as they venture into the new, unchartered waters of ICD-10. 

Consider the following five tips: 

1. Go back to the basics. Focus on high-risk diagnosis-related group (DRG) validation, monitoring the accuracy of the principal diagnosis, principal procedure, and any CC or MCC conditions. Include Recovery Auditor (RA) focus DRGs as well as high-volume, high-cost DRGs. 

2. Focus on specificity. Once you’ve established a satisfactory accuracy rate for DRG validation, take a closer look at unspecified codes. What is your unspecified code rate, and how can physician education help? 

3. Be flexible. ICD-10 is a moving target. New clarifications are published frequently, making it critical for organizations to develop and maintain internal coding guidelines in the absence of formal guidance. Consider creating a coder forum in which coders can exchange ideas and help each other navigate the maze of ICD-10. Then codify those decisions via formal policy and procedures.

4. Conduct an objective assessment of your coders. Use a reliable, unbiased tool to assess your coders’ ICD-10 coding. Use real records with proven ICD-10 answer keys, and assign the same cases to each of your coders and coding management members. This strategy will provide a true comparison among members of your coding staff.

5. Strengthen relationships. An external coding audit partner provides an unbiased view that can benefit organizations struggling to find a consensus among coders. A best practice in ICD-9 was to conduct an external audit only once a year. In ICD-10, a best practice will be to perform more frequent audits and to expand auditor expertise.

Here are three ways to strengthen your coding audit partnerships in 2016: 

  • Use your auditing partner as an arbitrator in cases involving large payors and your health system. Let the experts code and audit cases for which there are discrepancies between payor and provider interpretations of ICD-10. 
  • Verify auditor qualifications, including any experience auditing other providers.
  • Ensure that audits include a strategy for ongoing ICD-10 education and a process for vetting questions as they arise. 

A little skepticism is healthy

Don’t let the smooth transition to ICD-10 fool you into thinking that all is well in your revenue cycle, and particularly in your coding department. If your productivity and DNFB are up to par, take a closer look at your accuracy. Don’t wait for a string of denials to signal a coding problem.

About the Authors

Joseph J. Gurrieri, RHIA, CHP, vice president of HIM Services at H.I.M. ON CALL, has more than 20 years of experience in health information management. Joseph previously worked for the New Jersey Hospital Association (NJHA), where he was the assistant vice president of information services. He has held various positions in hospitals in New York and New Jersey, including assistant, associate, and director of HIM.

Cassie Milligan, an expert in coding and data quality, is the manager of quality improvement at H.I.M. ON CALL. With over 30 years of experience ON CALL. With over 30 years of experience and thorough understanding of HIM technology systems, including many encoders and EMR systems, Ms. Milligan is a talented asset for H.I.M. ON CALL and its clients. Prior to joining the H.I.M. ON CALL team she worked as a QA specialist in Meridian Health Systems, Jersey Shore University Medical Center division.

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