EDITOR’S NOTE: Dr. Anon is a U.S. physician based overseas who wishes to remain anonymous.
Following implementation of ICD-10, what has happened in the coding world as it pertains to outsourcing? The answer is simple: chaos.
For those of you old enough to remember, I am not describing a Get Smart episode with the international organization for evil known as KAOS – but the scenarios may mirror each other. There are now many coding vendors in India, the Philippines, Jamaica, and South America – put simply, although some American providers may have been listening to industry predictions of 40 to 50-percent drops in productivity and thus hired staff to train and deploy, others turned a deaf ear and did not heed the warning. So, what is currently happening?
1 Staffs in India (where labor laws are very loose) are being forced to work overtime and at least one weekend day per week. This may not be happening in the other outsourced countries, as labor laws may be tighter.
Impact analysis: Extra volume is everywhere, but due to mental and physical exhaustion among coders, a drop in quality inevitably will occur. How long can this mandated work schedule be sustained? Many coders seeing a favorable market have left vendors that are forcing this type of work schedule, leaving inexperienced staff with less than six months of experience to handle the workload.
2. Everyone, including auditors (a second set of eyes, and not really the definition that is widely known in the U.S.) has been deployed to meet client expectations.
Impact analysis: There obviously should be some oversight of coding quality, especially for those coming right out of training.
3. Vendor ICD-10 implementation coincided with acquirement of temporary/new ICD-9 business for those clients trying to get their internal staffs acclimated to ICD-10.
Impact analysis: There has been very little practice time on dual coding by vendor staffs due to the onslaught of new ICD-9 business. Therefore, unfamiliarity with subject matter during ICD-10 implementation, and without available QA staff, can create a massive impact on coding quality.
4. The outsourced staffs are utilizing outdated books (2014) and therefore erroneous codes or incorrect exclusion 1 exclusion 2 applications are being followed.
Impact analysis: Wrong codes or not enough codes are being applied to the claims, and this too is creating a drop in quality due to inadequate oversight.
5. In order to meet some expected production, the coders are hurrying through the charts and not reading the documentation, which will have a deleterious impact on the back end.
Impact analysis: Clients should be prepared for massive denials. This will mean that the claims appeal department and the billers will be putting in many extra hours of work to get the claims paid appropriately.
6. In order to meet volume, codes such as external cause codes are not being assigned on the claims.
Impact analysis: Although there is no national requirement for mandatory ICD-10-CM external cause code reporting, if there are state-imposed, payor-based requirements regarding the reporting, these will not be met and data capture will be incomplete.
7. Chronic conditions and history codes are not being captured on the claims.
Impact analysis: Not capturing the patient’s total clinical picture will impact case mix with a drop in severity of illness. Even a small change in CMI for IP might send the financial department into “suicide watch” because of the large impact on hospital revenue.
8. Whether by client design or coders rushing to get their quotas finished, many claims are being released with unspecified codes.
Impact analysis: This creates the possibility of denied claims for lack of specificity. Although the Centers for Medicare & Medicaid Services (CMS) has a moratorium of one year on specificity within a family of codes, this guidance only applies to Part B physician professional claims and not facility billing. Remember that the government dangled the carrot to get the providers on board for ICD-10 implementation.
9. There are huge backlogs with no end in sight.
Impact analysis: Reimbursement will be held up. Look at your DNFB and start to seriously question the vendors, forcing them to give you an action plan, because these backlogs will cripple your cash flow.
10. Claim submission filing limits are not being met.
Impact analysis: Denials abound. Make sure that you are working with the vendor to code claims with the highest dollar and shortest filing limits first. I don’t have to remind you that if you do not meet filing limits, you have no appeal rights.
There were some facilities that were proactive and forced the offshore vendors to prove that they had the resources to meet the ICD-10 expectations. They asked for detailed lists of coder names and they tracked attendance and short- and long-term leaves.
Why? In short, it was to prevent sharing of logins and account information for individual coder productivity. Were they micromanaging? Absolutely, but it was necessary to protect the reimbursement expectations. Those groups that left it up to the vendor to have a plan for ICD-10 without following up were not doing due diligence, making sure that projections were meeting the expected deliverables.
As a facility or provider group that has outsourced coding, you need to stay on top of what is happening to get the results that you are expecting. Don’t take the vendor’s word for it that what is expected is happening, because transparency may not be in place. Ask for a quality score on every single one of the coders assigned to your specific project. Run reports for codes expected to be found on claims such as accidents. Run reports on unspecified codes. Get involved in the project weeds, and don’t just accept an overview that everything is smooth sailing, because it is often not!
I hope that those of you that have outsourced your coding have also established a line of credit with a financial institution, because you may need it in the upcoming months.
You don’t want to be caught off guard if something drastically goes wrong.
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