Address documentation and coding issues up front, rather than correct them later.

Coders have had many challenges throughout the years.  When I started in the industry, we did not submit claims electronically; they were submitted on paper and we used an IBM Selectric Typewriter to complete what was then the HCFA 1500 (CMS 1500) or UB-92 (UB-04).  There were a few medical policies but very few and the coding was simple.  In fact, many payers did not even accept the CPT® or ICD-9-CM codes but just wanted a narrative description on the form.  How the world of coding has evolved and will continue to evolve and change in the future.  Coders play a vital role in the financial success of every organization small or large.

What challenges lie ahead for coders?  There are numerous challenges now which will continue in the future. 

  1. Code Changes and Staying Up to Date

One of the challenges coders always face each year are the coding changes.  Reviewing the code deletions, additions, guidelines revisions, and code revisions from all code sets CPT, HCPCS, and ICD-10-CM/PCS.  Communicating these changes to the practitioners is always a challenge.  Changes in the National Correct Coding Initiative edits has been and will be an ongoing challenge. Keeping up with codes bundled and when you can and cannot use an NCCI associated modifiers is always a struggle.  Practitioners don’t keep up with bundled code pairs and it is up to the coders to educate the practitioners and keep on top of the changes in the bundles. Coders should know what is included in each code they submit so they don’t submit an incorrect claim. Keeping abreast of these changes is key in submitting accurate claims to the payers.

  1. Clinical Documentation

The most challenging issue with clinical documentation is educating the practitioners in improving documentation to support the codes billed whether it be a CPT code, ICD-10 code or HCPCS code. Queries have become common place in both the hospital and office/clinic setting and not getting slow or no response from the practitioner can hold up claim submission or result is submitting incorrect coding.  Specificity in the diagnosis coding is still a huge challenge as most practitioners still are selecting unspecified codes or the documentation does not tell the entire story, so coders can select a code that is specific. 

  1. Communication

Lack of access to the practitioner is becoming more of a challenge for coders in particularly large group practices where coders don’t have direct access to the practitioner to discuss a patient encounter when there are questions.  Relying on queries to obtain the answer to questions is not always effective.  Practitioners keep making the same documentation and coding mistakes without good communication with the coders.

  1. Productivity

Productivity has been affected with the migration between paper and the electronic health record.  In many cases coders sometime have to double enter coding into the billing and clinical systems which creates a decrease in productivity. Many organizations have productivity benchmarks and claim submission deadlines which sometimes are difficult to meet with problem claims, documentation issues or the need for more information before the claim can be submitted.  There is a shortage of experience coders in the industry and many organizations are having difficulty finding experienced certified coders.  Coders that are entering into retirement are not being replaced fast enough with qualified coders.  It is most difficult to find experienced talent in rural areas and critical access hospitals.  Coders have to work harder with less people in many cases.

  1. Changing Regulations

Adapting to MS-DRG changes, E&M pending changes and other pending regulations is a challenge.  Payer policies are also evolving and changing. Even though a coder codes a claim correctly based on coding guidelines many payers have various medical policies as what supports medical necessity for a particular procedure or service. From my experience when educating physicians and coders, many struggle to even know how to research policies or where to find critical information they need.  Keeping up to on issues such as bundling edits, MUE’s, etc. can be daunting. As the coding requirements increase, it causes an additional workload for the coder.

  1. Continuing Education and Training

Many organizations don’t have the resources to provide continuing education for coders and some don’t see the value of continuing education which is a mistake.  Coders need on-going education to stay up to date with coding and regulatory changes.  Many coders are specializing now, and it is critical that they engage in education related to specialty annually at a minimum.  There are various methods of education now that are low or no cost, such as the Centers for Medicare & Medicaid Services (CMS) webinars and education opportunities, podcasts, webinars, white papers, and workshops.  Articles from professional associations can be invaluable in alerting coders of changes.  Also, the medical specialty societies have a wealth of information to educate practitioners as well as coders.  Many larger organizations engage in in-house training utilizing in-house talent to educate or hire outside educators to provide education.  But keeping up with the changes has always been a challenge.

  1. Failure to use Updated EHR templates

Electronic health record (EHR) templates should be reviewed and updated to coincide with coding and compliance changes.  I have seen many times when an organization implements a new EHR and fails to customize the templates to the department and/or specialty.  That is a huge mistake which can result in coding errors.  Coders and clinical documentation improvement specialists (CDISs) are challenged to assist with customizing and/or updating templates.  Many times, the templates are not updated or reviewed which can result in additional queries from the coders to the practitioner which can slow down productivity.

How can coders handle the challenges?  Take a deep breath and know that all coders in the industry face similar challenges.  Keep up to date on coding changes.  Realize continuing education is critical to your success. Address documentation and coding issues up front instead of having to correct the problem later.  Develop a line of communication with your practitioners to discuss documentation and coding issues.

Lastly, realize that you are a critical partner in the reimbursement process whether you work in a hospital, clinic, physician’s office or other healthcare facility.


Program Note:

Listen to Deb Grider report this story today on Talk Ten Tuesday at 10 a.m. Eastern.

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