Contents

OVERVIEW

Documentation – Be extravagant with your Documentation!

What Cosentus recommends for a robust documentation Strategy

Workflow – When was the last time you restructured your Coding Workflow?

What Cosentus recommends for an improved workflow Strategy

Skilled and Certified Coders – Deploy learned and certified coders only!

What Cosentus recommends as the essentials for a truly learned and certified coder Strategy

Specificity – Key to success lies in the detail!

What Cosentus recommends for specificity coding Strategy

Compliance Program – Staying out of harm’s way!

What Cosentus recommends for a strong coding compliance Strategy

OVERVIEW

Optimizing the efficiency and effectiveness of your revenue cycle operations must be the words buzzing across the boardroom of your healthcare organization every time all the stakeholders converge there. Medical Coding optimization of course cannot be ignored in this consideration, as it lays foundation for performance of other revenue cycle optimization strategies in the constant pursuit of this core business goal. Sustained revenue recognition can be greatly contributed by accurate coding. So, if your coding is accurate, your cash flow is most likely to be consistent, right? But, it is simpler to put it like this, than accomplished. Attaining consistent best coding outcomes requires methodical attention to various parts of this game on a continuous basis.

Cosentus makes an attempt through this White Paper on explaining some of those Medical Coding Optimization strategies that if paid invariable heed to can always keep your healthcare organization’s cash cycle hale and hearty! 

Documentation – Be extravagant with your Documentation!

Document more than less! Restrained and “economical” documentation of complete series of events of a physician-patient encounter can severely compromise coding accuracy. Incomplete documentation can also result in inappropriate codes, i.e., down-coding or even up-coding of the services rendered to a patient. It is, therefore, important to capture all elements of care provided in physician’s documentation of their medical records. The time spent on a patient visit, examination and/or procedures performed, and the reason for the visit should all be documented in detail in every patient’s record.

What Cosentus recommends for a robust documentation Strategy 

• Implement a Clinical Documentation Improvement (CDI) program. A CDI program can not only improve the data quality and translate into accurate reimbursement for your organization, but it can also provide for improved healthcare outcomes for your patient community.

• Hire a clinical documentation specialist to help improve your healthcare medical record documentation process. A CDI specialist can work towards harmonizing accuracy and quality amongst all players in the game, namely, doctors, transcriptionists, medical coders, and other ancillary healthcare staff. A CDI specialist may also help in maintaining charts, medical records, and work out any issues involving documentation.

Download White Paper Now: 5 Proactive Strategies For Optimized Medical Coding

Workflow – When was the last time you restructured your Coding Workflow?

Most coders prioritize their daily coding of fresh medical records over any other coding-related chores. It is obviously so because revenue cycle leaders want them to get most charges out the door in an expectation that the higher number of charges billed would convert into faster cash cycle. It may also be so because the number of coders required to handle the daily volume and the tasks associated with handling that daily volume may not be enough. This type of situation leads to coding-related denials being ignored or at least less prioritized. When this happens, denied claims keep stacking up in the background and thus keep silently slowing down the reimbursement process which ultimately results in an increase in accounts receivable (A/R). Most of the time, this increase in A/R attributable to coding-related denials is not even recognized until it becomes too late to be treated.

What Cosentus recommends for an improved workflow Strategy 

• Take a closer re-look at your current coding workflow.

• Hire more coders if staffing is identified as a problem in your coding workflow or better outsource your overflow coding volume.

• Have a team dedicated to working coding-related denials. If a dedicated team is not an option, ask coders to prioritize coding-related denials and then only move to coding of fresh charts.

• Working denials at the start of the day can expedite the re-submission of claims within timely filing limits and eventually bring about faster reimbursements.

• Working denials at the start of the day can also prevent the same, previous coding-related errors from reoccurring again later in the current day’s coding when the takeaways from working those denials are discussed in a group meeting as educational opportunities before coders start coding their current-day volume, so that every single coder in the team may come to know about the coding-related denial reasons that other coders have researched and resolved.

• Educational opportunities thus realized from working coding-related denials every day should be documented as policies and procedures in your coding profiles and also, if possible, shared with IT team to be built as edits and checkpoints within the practice management / coding workflow systems to help prevent those errors in future before claim submissions.

• Continual assessment of current workflow is vital for healthy cash flow and reimbursement cycle. Therefore, this assessment should be a periodic ritual.

Skilled and Certified Coders – Deploy learned and certified coders only!

Coding skills and certification go hand in hand in establishing and validating a coder’s knowledge. Having just one of these is no guarantee a coder is learned enough. Certified medical coders have both thorough understanding of translating medical language from reading the clinical documentation and converting that clinical documentation into codes that establish relation between the medical necessity and the treatment or services provided for that medical necessity. These codes ultimately become the basis on which insurance companies determine the most appropriate reimbursement for those services. Coders should, therefore, be extremely knowledgeable about the importance of medical necessity conveyed and the services reported through the codes assigned by them for each encounter.

What Cosentus recommends as the essentials for a truly learned and certified coder Strategy

Coder should have currently valid certification for your specific medical specialty from an accredited organization like AAPC or AHIMA. A valid certification ensures coder is up-to-date in knowledge and knows how to use ICD-10 official conventions, instructions, and guidelines as well as specialty-specific HCPCS/CPT coding.
Coder should be aware of National Correct Coding Initiative (NCCI) and should know the correct coding methodologies. A coder well versed in NCCI avoids reporting incorrect code combinations and prevents denials and improper payments in the first place.
Coder should be thorough in using LCDs (Local Coverage Determinations—determinations by a fiscal intermediary or a carrier under part A or part B as to whether or not a particular item or service is covered on an intermediary- or carrier-wide basis) and NCDs (National Coverage Determinations— nationwide determinations for Medicare covered services) as well as payer policies. This helps in preventing medical necessity denials.
Coder should be knowledgeable about correct use of appropriate modifiers and especially about the use of more frequently used modifiers like 25 and 59.
Coder should be knowledgeable about Medicare and how it works. This knowledge helps coder prevent insurance-related denials.
Coder should be knowledgeable about HIPAA to prevent any unintentional breach during the coding process and beyond.
Coder should have knowledge about Global Surgery Package.
Coder should have knowledge about Medicare Physician Fee Schedule (MPFS).
Providing your coders access to latest, up-to-date coding resources and online tools, including AMA’s CPT Assistant articles and AHA’s Coding Clinic, and other coding reference books holds equal importance in the overall game.

Specificity – Key to success lies in the detail!

 What Cosentus recommends for specificity in coding Strategy 

• Providers must share the responsibility of ensuring specificity in their documentation. Imparting provider education by way of evaluating the documentation and coding trend is one way of achieving this. 

• Coders must code each health care encounter to the level of certainty known for that encounter. Coder can query when in doubt, but this may not always be frequently practical as it can be workflow disruptive.

• Coders must use the most specific codes to accurately reflect the healthcare encounter. 

• Avoid coding signs and symptoms where definitive diagnosis is documented. 

• Per CMS, “If a definitive diagnosis has not been established by the end of the encounter, it is appropriate to report codes for sign(s) and/or symptom(s) in lieu of a definitive diagnosis. When sufficient clinical information is not known or available about a particular health condition to assign a more specific code, it is acceptable to report the appropriate unspecified code (for example, a diagnosis of pneumonia has been determined but the specific type has not been determined). In fact, you should report unspecified codes when such codes most accurately reflect what is known about the patient’s condition at the time of that particular encounter. It is inappropriate to select a specific code that is not supported by the medical record documentation or to conduct medically unnecessary diagnostic testing to determine a more specific code.”

Compliance Program – Staying out of harm’s way!

Healthcare organization delivering patient care cannot thrive without a strong coding compliance program and remains susceptible to risk of fraud without putting such a program in place. Only qualified staff should be allowed to develop an organization’s coding compliance program. The staff selected for this role should begin with a risk assessment exercise before creating a compliance program to ensure it incorporates provisions to address the areas most likely to get afflicted by risks. Stakeholders outside the coding function should also be involved when necessary to address cooperation required of them in areas such as provider documentation or updating the practice management software with necessary edits.

What Cosentus recommends for a strong coding compliance Strategy

• Define qualification and experience requirements for your coding roles at your healthcare organization.

• Establish commitment standards for your coders to code accurately as per the official coding guidelines and regulatory mandates.

• Document and keep updated an internal repository of policies and procedures for coding that identifies every step and practices followed in your coding process and actions required of coders during those steps for consistency of coding outcomes.

• Each coding specialty requires a different set of documents to enable coding within that specialty. For an example, outpatient surgery coding may require Surgery Schedule, Operative Report, History and Physical, Pathology Report, and Implant Logs. It is, therefore, important to outline these documentation requirements for each specialty within your compliance policy to ensure coders have or they request those documents before going ahead with coding.

• Payer policies related to coding practices need to be incorporated in coding profiles.

• Chart a calendar of continuing education and training for your coders and reinforce that with regular in-service training programs to address areas of improvement.

• Coding and regulatory changes can be frequent or periodic. Coders affected need to be made aware of these changes from time to time. Procedures should be established for such communication to take place in a timely and effective fashion. Policies and procedures affected by these changes should also be updated.

• Monitor your coding accuracy rate and pattern through periodic internal and external audits and take findings-based informed decisions to improve upon the existing coding trends. External audits should be at least a semi-annual ritual if not more frequently, as sometimes you need an outside viewpoint to discover fresh perspectives.

• Lastly, provisions should be made for corrective and/or disciplinary action for those not following the norms laid out by the compliance policies and procedures.  

CONCLUSION

Accurate medical coding has the potential to produce tangible benefits for healthcare organizations. Cosentus appreciates the complexities of medical coding like none other in the revenue cycle management industry. Our coding solutions create opportunities for better cash flow and faster revenue recognition.

Why Settle, When More Awaits!

SOURCES:

1. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1518.pdf.

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Disclaimer:

The information contained in this publication is provided solely for educational purposes. Cosentus LLC, nor the author, offers any legal or other professional advice. Every effort has been made to make this white paper as accurate as possible. However, there may be errors. Therefore, this publication should serve only as a general guide and not as the ultimate source of subject information