We all did so well with preparing for ICD-10 implementation, didn’t we! We had great education and training provided, and coding reviews and assessments were conducted in the years prior to implementation. We even performed dual coding and practiced coding encounters/cases. Now, with six months of experience under our belt, is NOT the time to slow down coding reviews, audits, and education.
As the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) has announced seven elements within its Compliance Program Guidance recommendations, we need effective education and training and to conduct auditing and monitoring.
All healthcare settings need to have in place coding reviews, audits, and/or assessments. Although the word “auditing” often creates fear and anxiety, we need to communicate, and to look upon this process as a learning experience that can help improve overall quality of our coded data. But using the word “review” or even “assessment” does have a little more positive connotation.
If you look at the ICD-10-CM Official Coding and Reporting Guidelines, you’ll find this statement at the beginning of the instructions:
“The official adherence to these guidelines when assigning ICD-10-CM diagnosis codes is required under the Health Insurance Portability and Accountability Act (HIPAA). The diagnosis codes (Tabular List and Alphabetic Index) have been adopted under HIPAA for all healthcare settings.”
These Official Guidelines can serve as a resource for your reviews and for the auditing staff and/or consultants, as well as for coding education. Another resource will be the American Hospital Association (AHA) Coding Clinic on ICD-10-CM/PCS. It is essential for all coding professionals to have access to AHA Coding Clinic. But don’t stop there – be sure that your coding staff read through the publication each quarter and then confirm their understanding of the content. Understanding the guidance sometimes takes reading it more than once and then discussing it with your peers. Remember, previously published advice on ICD-9-CM is still relevant and applicable to ICD-10, according to AHA Coding Clinic, unless there is a new, specific guidance. Yes, there are similarities and differences between ICD-9-CM and ICD-10-CM/PCS, so read carefully.
Coding accuracy and consistency should be evaluated critically, and a documented process or plan should be in place to maintain this quality. Whether you conduct reviews or audits that are internal, external, or a combination of both (I like to see both), conducting a coding review is important to complete now, and several times each year going forward.
First determine if you’ll be conducting a random or focused review. A random review will help provide a baseline of your ICD-10 coding accuracy. You’ll also need to determine the size of the review or audit, meaning how many encounters will be reviewed, by setting. Discuss this with your review or audit team and within your organization, because funding, staff resources, and time commitment may be factors in determining the size of the audit sample.
Have a written purpose for the review, and when defining the scope, take the following into consideration (at a minimum):
- Type: concurrent, prebill, or retrospective
- Focus: MS-DRGs, specific code(s), targets from past audits, etc.
- Setting: Hospital inpatient, outpatient, or both; physician, skilled nursing, etc.
- Date Range: October-November 2015, first quarter of 2016, etc.
- Encounter Frequency: (number of encounters): 25, 50, or 100 (per setting, clinic, provider, or hospital)
- Payer: i.e. Medicare only, or all payers
- Provider: Specific (if applicable – often included in a physician profee review)
- Coding Staff (individual): If applicable
Some action items to consider when conducting an ICD-10-CM/PCS coding review (this is not all-inclusive):
- Review and compare data to see if there is variation from national averages due to inappropriate coding, insufficient documentation, or lost revenue. Also look at your own data since Oct. 1 and see if there are frequencies of certain codes that would seem unusual, as those may be areas to review.
- Use the targets of the Recovery Auditors (RAs) or Zone Program Integrity Contractors (ZPICs) for your review scope.
- Validate the accurate diagnosis and procedure code assignment or selection (confirm compliance with guidelines and instructions).
- Identify if the code assignment is supported by the physician/provider documentation.
- Validate when an “unspecified” code was assigned if specific documentation is/was provided.
- Validate when a “specified” code was assigned/used if the documentation is/was specific.
- Confirm the accurate sequencing of the codes to ensure that the Official Guidelines are being followed and the codes supported by the clinical documentation.
- Identify if a physician query should have been initiated; there are several coding guidelines that specifically instruct to query the provider. If a query was used, identify if it was compliant or not (use the American Health Information Management Association, or AHIMA, 2013 Practice Brief on Physician Querying as a resource).
- Validate the present-on-admission (POA) assignment (inpatient).
- Validate the discharge disposition status code accuracy (inpatient).
- Identify and correct problem areas of incorrect coding; if there are negative patterns or trends, put a corrective action plan in place.
- Identify any reimbursement differences or deficiencies due to the addition, change, or deletion of a code; follow the Centers for Medicare & Medicaid Services (CMS) 60-day timeline for resubmission once a coding variance has been identified that impacts reimbursement.
Once the review is completed, you’ll want to have the findings gathered and put into a written summary, including individual worksheets for each encounter with a coding variance. Share the findings with your coding staff, discuss the individual findings (per case), and determine what could have been the source of the variance (error) – for example documentation that was present was missed when coding or a guideline not followed, etc. Once agreed to, make the necessary coding corrections and rebill when reimbursement is impacted.
Next is coding education, which needs to continue – and this comes in all shapes and sizes – but at this stage we should use the coding review results to feed our educational content and curriculum. Face-to-face instruction has become less frequent due to remote staffing models; however, live webex can be used to provide high-quality education. For general coding education, you can record and then allow for the recordings to be played back at any given time. Ensure that you have content that fits the educational focus and setting, and outline the goals and objectives of the educational session.
With each coding education session allow time or include the coding of actual cases (scenarios) to help solidify the learnings. To actually practice coding is a great way to learn and to drive consistency in coding practices!
Also visit the AHIMA website and the websites of state professional associations for their array of educational programs, seminars, webinars, and conferences. All can provide excellent content to help enhance coding knowledge or clarify certain aspects or sections of diagnosis (ICD-10-CM) and/or procedure (ICD-10-PCS) coding. There are many opportunities for coding education across the industry of which to take advantage.
Now that the review has been completed and the education has been conducted, you’ll want to start the planning for the next review. Yes, this is a repetitive process, but necessary to obtain and maintain coding accuracy, quality, and compliance. Keep moving forward with consistent coding reviews and education, as this will help us all obtain quality coding and data integrity.