Without medical coders, the healthcare system would come to a halt. These professionals are responsible for coding information documented by physicians, nurse practitioners and physician assistants into the correct format for billing and reporting purposes. Accurate and compliant coding is critical for several reasons. Not only does it drive reimbursement for services, but it also generates robust epidemiological data and affects public perceptions of healthcare organizations.
Becker's Hospital Review recently spoke with Amanda Hyer, chief product owner at 3M Health Information Systems (HIS). The compliance expert with more than 15 years of experience discussed the challenges associated with coding and the benefits of coding quality and compliance programs.
Standards, staffing and systems create coding compliance challenges
Each year, coding guidelines are issued by CMS and the American Medical Association. These define how providers should report information related to procedures and patient diagnoses. New guidelines are typically published each October, but it is not uncommon for updates to come out on a quarterly basis. In addition to these standards, providers also must adhere to payer coding guidelines.
"There are so many different payers that it's often difficult to figure out how information should be coded," Ms. Hyer said. "Sometimes payer guidelines conflict with the AMA and CMS directives. In addition to staying up to date with different coding guidelines, providers must also be aware of guidance about when procedures are supported for medical necessity."
Additionally, it can be difficult for providers to find coding talent in some markets. As a result, it's common for health systems to use remote coding teams. Communicating with these teams can create challenges for organizations.
Technology-based coding compliance programs can help
Robust coding quality programs define what information will be audited, when it will be reviewed and how feedback will be provided to key stakeholders. A best practice is to focus on risk areas identified by the HHS' Office of the Inspector General (OIG). These risk areas are of particular interest to third-party administrators during audits.
"Whether you conduct coding quality audits on a weekly, monthly or quarterly basis, one of the most important elements of a coding compliance program is the feedback that goes back to the coders, the clinical documentation improvement group and physicians," Ms. Hyer said.
Centralized coding audit tools that integrate with EHR and billing systems, as well as current coding guidelines, can increase efficiencies and reduce waste. These tools should include analytics and the ability to share metrics with key stakeholders.
Coding quality metrics vary by stakeholder group
The C-suite focuses on metrics related to the bottom line, such as how coding audits impact revenue. "Sometimes audits are very beneficial from a financial perspective. We find missed revenue and can capture that," noted Ms. Hyer.
For coders, accuracy is the most common metric. From a quality standpoint, coders are required to work at a 95 percent accuracy rate.
Providers also have an interest in coding quality metrics, since their pay is affected by coding errors. This is particularly true for physicians practicing in outpatient settings. Typically, physicians are very interested in seeing and improving their metrics.
A best practice is to appoint a physician champion to work closely with the compliance team. Most physicians are more receptive to hearing constructive feedback from a peer than from someone in the coding realm.
Better provider documentation enables coders to do their work more accurately. "Providers have good intentions, but they sometimes miss details because they are rushing from patient to patient. Giving them feedback definitely supports better outcomes for coders," said Ms. Hyer.
Keeping coding proficiency at the forefront has a trickle-down effect in organizations. Everyone has to contribute, not just coders. Accuracy begins with providers who are writing the information. When top leadership conveys a consistent message about accuracy, organizations typically have better coding compliance programs.
Conclusion
Without high-quality, compliant coding, health systems can't operate efficiently. However, the importance of coding accuracy goes beyond financial and operational issues. It also can affect the brand image of healthcare organizations. If a health system gets into trouble with the OIG, that news will be broadcasted across all major media and cause patients to question the service quality.
"I think we sometimes forget the 'why' and 'how' of doing having a coding quality compliance program. It isn't just to get paid. It all comes back to educating coders and providers about new trends, as well as how we capture information," said Ms. Hyer.