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True or false: October 2014 will be here before we know it. But with the efforts, costs and time going into preparing for ICD-10, once you have made it through the main implementation tasks and your claims are being processed successfully by all payors, you can take a breath, sit back and relax.

If you answered “true,” or if you were hoping the answer would be “true,” you’d best revisit your game plan.

A part of all ICD-10 readiness plans, including budget planning, should be a post-implementation maintenance plan as well. A major part of any maintenance plan should focus on your coding staff as well as ongoing documentation challenges.

External Forces

With increasingly complex government legislation, regulations and investigations being enacted, healthcare organizations continue to struggle to ensure the existence of complete and accurate documentation and compliant coding practices. These struggles and external stressors are not going away with the implementation of ICD-10. And the impact of ICD-10 on external forces very well may feed initiatives and efforts to identify improper coding and billing under this new coding system.

Why Routine Coding Audits?

Following implementation, with ICD-10 nuances surely still being new to coders, coding accuracy rates may drop for a time, along with productivity. It is vital to ensure that accuracy remains consistently high, however.

The way to minimize risk and regulatory exposure, to receive appropriate reimbursement, and to ensure the existence of a complete and accurate database through precise coding beyond ICD-10 implementation is to perform routine coding and documentation audits. This will offer coders feedback and education, increasing morale and confidence.

Remember, efforts to achieve comprehensive documentation and precise coding can lead to a complete and accurate database, which in turn will lead to:

  • Accurate case mix index (CMI) and reimbursement
  • Accurate reflection of severity of illness (SOI) and risk of mortality (ROM)
  • Support of medical necessity for services rendered
  • Support of decisions to admit and verification of medical necessity for inpatient or outpatient status
  • Adherence to regulations
    • This wards off government and payor scrutiny in the form of auditing by RACs, the OIG, ZPICs, MICs, MACs, etc.
  • Improved comparison studies and profiling/scorecards
  • Proper management of HealthGrades, Leapfrog, state comparison studies, PEPPER reports, PQRS
  • Support of resource consumption and length-of-stay parameters
  • Support in contract negotiations (payors, for managed healthcare)
  • A decreased number of rejections and denials, including hospital-acquired condition/present-on-admission concerns and discharge disposition issues
  • Assistance with research, outcomes analysis, quality of care, critical pathway development, wellness initiatives, etc.
  • Reduced penalties related to 30-day readmissions; the excess readmission ratio includes adjustments for factors that are clinically relevant, including comorbidities
  • Accurate planning for population management and accountable care data analytics

The Plan

So, when should we get started?

Many facilities are planning to perform dual coding prior to the implementation date, or coding records in both ICD-9 and ICD-10. This will allow for the start of an ICD-10 database, prompt early financial and clinical comparison studies, encourage assessment of documentation issues and coder productivity impacts, as well as offer the coders hands-on experience.

Post-implementation coding quality maintenance plans actually should start to be executed when ICD-10 coding begins, even if it is prior to the implementation date.

How frequently should we review, however, and on how many claims?

Initially, when ICD-10 is still new to the coding staff and as they gain experience, confidence, and increases in productivity, 100 percent of the records coded in ICD-10 should be reviewed for accuracy. An eye also should be kept on the potential need for additional educational tools for coders and documentation educational resources for providers.

Plan to reduce the volume of codes from 100 percent to 75 percent, then down to 50 percent and 25 percent, until you reach a manageable ongoing routine maintenance volume. The results of the ongoing reviews should suggest when to change volumes, and whether they should be decreasing or increasing. As results improve and expected accuracy rates are achieved and maintained among all coders, the volume that is reviewed can be reduced. Precyse defines “achieved and maintained” as performing at least three consecutive reviews with expected accuracy rates achieved on each.

Accuracy rate expectations should be established up front for MS-DRG/APR-DRG designation as well as for total data quality (accuracy of all ICD-10 codes reported), for both inpatients and outpatients. Precyse recommends an accuracy rate of 95 percent or higher for the DRG assignment, for inpatient total data quality (all codes reported), and for outpatient diagnosis code reporting.

To determine the frequency at which maintenance plans are executed, the following are the various intervals organizations most commonly choose when coding audits, listed from strongest to weakest. As a rule of thumb, the more frequent the audits, the better accuracy can be ensured.

  • Daily: Performing a daily pre-bill review focusing on cases at high risk for coding error will allow for consistent billing accuracy on such cases from week to week throughout the entire year.
  • Quarterly: This allows for feedback to reach the coding staff four times per year.
  • Semi-Annual: This offers information related to coding only twice per year.
  • Annual: This offers only a snapshot of coding and documentation quality. A once-per-year coding audit by no means will provide a complete picture of the quality of an organization’s documentation and coding practices; if issues emerge, they may not be identified and addressed until the annual review is performed.

What do we include in the review?

Inpatient reviews should include a variety of payor types and a variety of clinical case types (infectious, neoplasm, respiratory, cardiology, obstetrical, complications, injuries, etc.).

Outpatient reviews should span the various outpatient services coded by HIM coders (ED, outpatient surgery, observation, X-ray, etc.).

Chart selection should begin as a random process covering a wide variety of clinical scenarios. As reviews continue, they may move to a more targeted chart selection process based on identified errors, patterns and trending issues, possibly switching back and forth between targeted and random reviews.

The Cost

Coder productivity is expected to be impacted significantly by the transition to ICD-10. Record auditing will experience an even greater impact. Auditors seasoned in ICD-9 often know the codes without having to look them up. Such auditors even can skim through assigned codes and immediately identify certain obvious coding errors. These skills are valuable for coders now, allowing them to quickly navigate the auditing process. But under ICD-10, code will have to be looked up and verified.

If you are planning to perform routine internal coding reviews, evaluate historical costs and time involved with prior reviews, also taking a look at coder feedback and education. Assess your ability to perform reviews as needed. Do you have the staff with the appropriate training, skills and time to perform routine reviews? Does your budget support this?

Following implementation, the need for external vendor support to validate the accuracy of coding across the country is expected to be vast. If you are planning to utilize an external agency to assist you with routine coding reviews, but do not yet have a vendor, establish a relationship with one now. Check with your current vendor regarding their internal consultant ICD-10 training plans. Make sure they have (or will have) the appropriate skills and staffing to assist you as needed. Find out what training plans and quality measures they are implementing for their own employees. Inquire about costs for future auditing under ICD-10, and expect the cost to increase drastically. If you do not already have a relationship with an external vendor, or if your current vendor will not be able to support your routine ICD-10 coding and documentation review efforts, again, start looking to establish a new relationship for this initiative now.

Choosing a Coding Audit Vendor

A trusted vendor partner can be invaluable in helping an organization develop and maintain a complete coding quality compliance program. When choosing a vendor partner to perform coding audits, consider the following:

  • References: Talk to other organizations about their experiences with various vendors and find out which ones they recommend and which ones they do not.
  • Range of services: Choose a partner with the ability to perform a wide variety of audit types, not just one specific type, such as MS-DRG validation.
  • Versatility: Choose a partner that is experienced with both on-site and remote audits, both small and large facilities, and both individual and multiple-facility audits.
  • Reporting capabilities: Make sure the vendor’s reports give statistical findings that will help identify patterns and trends in coding and documentation.
  • Audit process: Discuss the vendor’s audit process to ensure that it includes strong coder involvement, allowing for coder comments and chart-specific discussions.
  • Auditor training: Request information about the vendor’s audit staff in terms of their experience, credentials, education, tenure and training.
  • QA program: Ensure that the vendor has an internal quality check and internal QA program for its auditors.
  • ICD-10 training plans: Determine if the vendor’s internal auditing team includes an ICD-10 training component for their internal auditors and their clients.

With the implementation of ICD-10, many hospitals and providers are looking to vendors to assist them with education and training, and later with ongoing monitoring for accuracy through auditing. The industry is facing a shortage of qualified and trained coders today, and this will become an even greater challenge in the future under ICD-10; vendors are faced with this same challenge. It is important to partner with a strong and qualified vendor today to ensure that support is in place tomorrow.

The Complete Coding Quality Compliance Plan

Make sure that your ICD-10 plans involve and budget for post-implementation coding quality validation maintenance audits. Do not sacrifice the quality of your database during the transition from ICD-9 to ICD-10; ensure accuracy in ICD-10 immediately and on an ongoing basis.

And remember, a trusted vendor partner can go a long way in assisting organizations in developing the best coding audit compliance plans, based on their specific needs.

About the Author

Lisa Marks, RHIT, CCS, is director of client audits for Precyse (www.precyse.com).

To comment on this article please go to editor@icd10monitor.com


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