The Value of a Certified Coder and CDI in our Practices

With good collaboration and the right team members, continual improvements are attainable.

Recently I have been engaged in a project of continual improvement in our clinics, and as chief compliance officer, I am continually looking for ways we can stay compliant, deliver excellent healthcare, and fix revenue leaks.

We audit our physicians on a quarterly basis until they reach our pre-assigned accuracy rates, then they are audited on an annual basis. After each audit, one of our certified coders trains the physician on their results, along with their techs or scribes. The education is tailored specifically for each team.

While the education and audits were helping us retroactively address problems and potential improvements, there was nothing in place to help us proactively reach those same goals. Even though we were tracking significant progress, the results were slower due to the process.

It was then that we began engaging in a formal coding scrubbing program. Using certified coders, we evaluated documentation prior to the claims being submitted. The results have been phenomenal.

In our model, we do not have the coders review every single claim; this is cost-prohibitive and can slow down the overall process. We know what we do well, and we allow those claims to go through based on the physician coding choices. Instead, we use a targeted method. In our model, we scrub for the following:

  • Any risks identified during audits
  • All surgical claims
  • All claims that include diagnostic testing
  • High-cost injectables

Our main purpose for the program is to remain compliant while making sure we are protected where we have identified the most risks. We are able to find thousands of dollars in missing charges for most providers each week. The program is fluid, and it changes as new risks and opportunities are identified.

The most important part is the continual education and engagement of the entire team. Without great collaboration, success is limited.

In addition to the missing charges, we have found many areas ripe for improvement that we were able to act on quickly rather than retroactively at audit time. In addition, we were able to address noncompliant behaviors in real time, allowing us to become a very compliant organization. For our practices, we were able to identify:

  • Wrong levels chosen
  • Missing interpretation and reports
  • Issues with the setup of our new electronic medical record (EMR)
  • Injections billed at wrong units or missed
  • Not all surgical procedures being captured

The continual focus on clinical documentation improvement (CDI), with the education and the addition of new coding scrubbers, has allowed us to generate over a million dollars in one year in one of our larger clinics that has 46 providers. That was after fixing miscoding identified on coding scrubbing.

The teamwork being exhibited is amazing. When a problem or improvement area is identified, the team works directly with the providers. The providers are much more engaged, and love knowing what is going on. In addition, by engaging their ancillary staff, everyone understands their role in the documentation journey to excellent patient care.

For those practices that don’t feel they can afford a certified coder, this model demonstrates that you really cannot afford to go without one. You must be sure to be consistent in your processes, and education is a must. Teams must be engaged and willing to change for the better. With good collaboration and the right team members, you can see continual improvements.

It’s also important to note that while we have seen amazing results in revenue, that cannot be the driving focus of the program; you must address the overall needs of the practice, and involve compliance in your improvement efforts.

Comment on this article

Print Friendly, PDF & Email
Facebook
Twitter
LinkedIn

Related Stories

How to Report New Code Category W44

How to Report New Code Category W44

One of the goals of medical coding is documenting encounter notes to the highest degree of specificity. ICD-10-CM had some existing codes for documenting foreign

Read More

Leave a Reply

Please log in to your account to comment on this article.

Featured Webcasts

Leveraging the CERT: A New Coding and Billing Risk Assessment Plan

Leveraging the CERT: A New Coding and Billing Risk Assessment Plan

Frank Cohen shows you how to leverage the Comprehensive Error Rate Testing Program (CERT) to create your own internal coding and billing risk assessment plan, including granular identification of risk areas and prioritizing audit tasks and functions resulting in decreased claim submission errors, reduced risk of audit-related damages, and a smoother, more efficient reimbursement process from Medicare.

April 9, 2024
2024 Observation Services Billing: How to Get It Right

2024 Observation Services Billing: How to Get It Right

Dr. Ronald Hirsch presents an essential “A to Z” review of Observation, including proper use for Medicare, Medicare Advantage, and commercial payers. He addresses the correct use of Observation in medical patients and surgical patients, and how to deal with the billing of unnecessary Observation services, professional fee billing, and more.

March 21, 2024
Top-10 Compliance Risk Areas for Hospitals & Physicians in 2024: Get Ahead of Federal Audit Targets

Top-10 Compliance Risk Areas for Hospitals & Physicians in 2024: Get Ahead of Federal Audit Targets

Explore the top-10 federal audit targets for 2024 in our webcast, “Top-10 Compliance Risk Areas for Hospitals & Physicians in 2024: Get Ahead of Federal Audit Targets,” featuring Certified Compliance Officer Michael G. Calahan, PA, MBA. Gain insights and best practices to proactively address risks, enhance compliance, and ensure financial well-being for your healthcare facility or practice. Join us for a comprehensive guide to successfully navigating the federal audit landscape.

February 22, 2024
Mastering Healthcare Refunds: Navigating Compliance with Confidence

Mastering Healthcare Refunds: Navigating Compliance with Confidence

Join healthcare attorney David Glaser, as he debunks refund myths, clarifies compliance essentials, and empowers healthcare professionals to safeguard facility finances. Uncover the secrets behind when to refund and why it matters. Don’t miss this crucial insight into strategic refund management.

February 29, 2024
2024 ICD-10-CM/PCS Coding Clinic Update Webcast Series

2024 ICD-10-CM/PCS Coding Clinic Update Webcast Series

HIM coding expert, Kay Piper, RHIA, CDIP, CCS, reviews the guidance and updates coders and CDIs on important information in each of the AHA’s 2024 ICD-10-CM/PCS Quarterly Coding Clinics in easy-to-access on-demand webcasts, available shortly after each official publication.

April 15, 2024

Trending News

SPRING INTO SAVINGS! Get 21% OFF during our exclusive two-day sale starting 3/21/2024. Use SPRING24 at checkout to claim this offer. Click here to learn more →