While some have said medical coding sits quietly in the middle of the healthcare revenue cycle, it is a key step that, when done inadequately, can impact each part of the revenue cycle after it. Medical coding quality is crucial to ensuring claims get out the door quickly and reimbursements come back complete.
Yet, hospital finance leaders identified clinical documentation and coding as their greatest revenue cycle vulnerability in 2019. Recent events like the COVID-19 pandemic and increases in value-based reimbursement have only made medical coding more vulnerable to lost or decreased revenue.
While some challenges with medical coding quality stem from the fact many medical coders work remotely, providers can still implement strategies to improve quality and ensure accurate reimbursement whether coders are in-house or working remotely. Based on the literature and insights from industry experts, those strategies include leveraging technology, performing coding compliance audits, and creating a robust education program.
Leveraging technology
Electronic health records revolutionized medical coding, bringing the paper-heavy process into the digital age. While the EHR system is still key to the medical coding process, other technologies have emerged to improve the quality and accuracy of medical coding.
Computer-assisted coding (CAC) solutions, for example, are software products that can analyze healthcare documents to identify the appropriate medical codes for clinical documentation in the documents. The solutions speed up the medical coding process, while also increasing coding accuracy and efficiency, according to a report from AHIMA.
More recent data from the market research firm KLAS also shows that providers are very satisfied with their CAC solutions. About 94 percent of users said they would buy the CAC solution again.
Revenue cycle management solutions are also optimized for inpatient and outpatient coding and audits, according to the majority of respondents in a recent HIMSS Media research study.
But providers should still look to their EHR systems for help with medical coding quality. Just like the revolution medical coding went through with the advent of electronic health records, the systems that store those records have also evolved.
Providers should ensure EHR systems are able to capture everything coders need to for a correct and complete claim, especially in a value-based world.
Performing coding quality audits
While coding technology has streamlined medical coding, coding quality audits are still an essential component of a comprehensive medical coding improvement strategy.
Over $262 billion in claims are initially denied every year largely due to insufficient clinical information, according to a 2017 Change Healthcare study. Moreover, the study found that $28 billion in the denied funds were directly linked to a lack of clinical documentation.
Ensuring medical coding practices are up to payer code can prevent these “soft” denials that require additional information for reimbursement. Internal audits of these practices can identify areas or types of cases that are leading to revenue leakage whether because of bad habits, workflow issues, or even lack of training.
Audits should determine any differences between an organization’s billed data and the national average, United Audit System’s Kathryn DeVault, manager of HIM consulting services and Mary H. Stanfill, vice president of consulting, said in an article for the Journal of AHIMA.
“Identified variations may or may not indicate potential fraudulent or abusive coding and billing practices. However, variations require further analysis to determine if there is a compliance issue,” wrote DeVault and Stanfill.
For audits to be effective, they should be carried out regularly, added Sue Belley, RHIA, the manager of content and outsource services at 3M Health Information Systems.
Health IT companies can perform audits for organizations to gain an outsider’s perspective, but providers should still conduct regular internal audits to catch coding issues impacting medical coding quality, Belley indicated.
Opening communication lines
Whether internal or external, coding quality audits can uncover key ways to improve medical coding quality. But without a robust education and training program in place, audit findings are nothing more than that.
Providers should communicate audit findings and any changes in coding compliance with coders as soon as possible. Communicating areas ripe for improvement will enable coders to alter workflows immediately to improve coding quality. Communication also ensures coders are on the same page with updates to coding compliance, especially when the unexpected happens.
“The spread of COVID-19 is a good reminder for those in the coding profession to refine their processes around viruses and other issues that have the potential to change coding processes. When a new illness is on the horizon across the country, leaders should be proactive about how to standardize processes within their organizations,” said Charniece Martin, MBA, RHIA, CCS, CCS-P, revenue integrity analyst at Northwestern Medicine.
Audit results should also be shared across the revenue cycle and with clinicians to implement meaningful change for coding quality improvement. Since coding impacts every part of the revenue cycle after it, engaging stakeholders at every point in a case’s journey before it will help to ensure a smooth revenue cycle.
Communicating audit results and coding compliance changes with clinicians can be especially beneficial since they are the ones documenting clinical encounters, which will then be translated into claims for reimbursement.
Ensuring high-quality medical coding is important for capturing revenue. But as COVID-19 has taught the healthcare industry, it is also critical to keeping up with unexpected changes that have left many providers without the resources needed to deliver care.
The healthcare industry should also be prepared to such events and as providers move to value-based reimbursement, guaranteeing medical coding quality will be key not only for getting paid for services but capturing the quality of care delivered.
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Photo courtesy of: RevCycle Intelligence
Originally Published On: RevCycle Intelligence
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