Improving clinical documentation quality, leveraging technology, and educating providers are key ways hospitals improve coding compliance in a value-based world.
Medical coders are typically behind the scenes of patient care, analyzing records, selecting codes for billing, and managing patient data. But to Jannifer Owens, a revenue cycle expert with over 20 years of coding experience at small and large hospitals, coders are storytellers and their stories are crucial to hospital billing and quality coding compliance.
“What coders are doing is telling the correct story about why a patient was in the hospital or came to visit the physician,” the current revenue cycle content manager at 3M says. “If I were a payer or another provider, I should be able to just pick up a claim, look at the code, and then understand what happened to the patient during a visit based on the coder’s work.”
When payers and providers can pick up a bill and understand the patient’s story, then hospital billing and coding compliance gets easier, Owens reasons. Coders should tell the complete story by following billing and coding guidelines. By doing so, they can identify all the pertinent information and avoid missing codes that could impact reimbursement or care delivery.
Using coding guidelines to tell the patient’s story also supports hospital quality compliance, she adds.
Organizations are quickly moving to alternative payment models that tie reimbursement to quality performance. Coders enable providers to comply with those contracts by ensuring hospitals correctly capture metrics like Hierarchical Condition Category (HCC), value-based purchasing, Agency for Healthcare Research and Quality (AHRQ), and other codes.
“Not only is coding about capturing the things we need to from a payer perspective, but it also helps to ensure that the next clinician who takes a look at that patient can see the whole picture, which in my mind would help to improve the quality of care that we’re providing,” Owens states.
Medical coding is a staple of hospital compliance, and when done right, it can elevate a hospital’s billing and quality performance. But many hospitals and health systems are failing to recognize the coder’s role as storyteller.
Hospitals are still putting as much 3.3 percent of their net patient revenue at risk because of claim denials, which indicates possible coding inaccuracies and claims management inefficiencies.
Bringing coders out of their back-office silos and enabling them to do more than get a claim paid will help hospitals and health systems prevent denials, submit clean claims, and ultimately improve patient care at their organization.
Improving Clinical Documentation Quality
Clinical documentation quality is the biggest challenge of medical coding. A recent study, for example, found that EHR documentation and what actually happened during a clinical encounter only matched between 38 and 53 percent of the time.
Coders cannot tell the complete story if clinical documentation does not contain the information needed to code a patient encounter properly, Owens explains. To elevate coding’s role in compliance, hospitals and health systems should invest in a clinical documentation quality manager, she advises.
Unlike a traditional clinical documentation improvement specialist, the documentation quality manager is responsible for improving the technical component of documentation and coding. The manager should collaborate with hospital departments to review their documentation practices and identify opportunities for improvement through technology.
For example, a documentation quality manager at a hospital Owens used to work for optimized the organization’s EHR templates to how providers documented encounters. The templates especially helped NICU physicians ensure all diagnoses remained on a patient’s record throughout the stay, which was a major issue at the organization leading to lost revenue.
Hospitals with the resources to hire a documentation quality manager should find an expert coder who has clinical experience to speak with providers effectively, Owens advises.
But even if an organization does not have the resources to hire an additional staff member, they can improve documentation quality by reviewing documents and templates in the EHR, computer-assisted coding systems, and other technologies, she adds.
Using Technology To Improve Documentation, Coding
Technology has the potential to streamline and optimize claims management and reimbursement, yet many hospitals are not leveraging solutions. Automation is at or above 80 percent for just three of seven claims management transactions, and some transactions like prior authorizations are actually becoming more manual, the Council for Affordable Quality Healthcare reports.
But technology can make the jobs of coders and clinical documentation improvement specialists easier, Owens says.
Computer-assisted coding (CAC) solutions, for example, extract information from patient records and push it to the coder, which allows coders to focus on creating a story. Hospitals are also reaping the benefits of CAC solutions. Ninety-four percent of CAC users said they would purchase the technology again, according to a recent KLAS report.
The technology can also help coders prioritize their work to focus on accounts that will have an impact on the organization, Owens says. The solutions, for instance, can prioritize claims by DRG or payer so clinical documentation specialists and concurrent coders do not have to sift through hundreds of claims to identify the accounts that need additional information to tell the complete story.
In addition to new technology, Owens also advises hospitals to look at their existing solutions like the EHR.
“You think about the inception of the EHR and the way that our world was back then, and it’s not exactly the same as what we’re doing now,” she explains. “Some of the compliance things that are required now were not required back then, and we have to take another look at our systems to make sure that we’re capturing everything we need to.”
Provider, Staff Education Breaks Down Silos
Technology has the potential to optimize coding compliance, but the systems are also key to addressing a top challenge of coding compliance: provider education.
Coders and compliance staff have traditionally had an adversarial relationship with physicians and other providers. Providers do not want to be told how to deliver medicine to maximize reimbursement, and additional documentation and coding requirements can lead to burnout for providers.
Coders and compliance staff should be emphasizing why they need physicians to document a certain way to overcome the challenges of education, Owens suggests.
“If you can explain why they need to do something, then they are more willing to make changes,” she says. The same concept applies to staff education, she adds. Coders should know why it is essential to tell a patient’s story, which includes success in value-based arrangements and care quality improvements.
Technology can help break down the silos between providers and compliance staff, as well as coders and clinical documentation improvement specialists.
“With these tools, we have the ability to collaborate, which provides many more efficiencies,” Owens states. “For example, a quality nurse wants to know about the use of a certain diagnosis. Through the tools, the nurse can ask the coder to help her understand why something was coded in a certain way. She doesn’t have to wonder or surmise that coding doesn’t know what they’re doing.”
Every department plays a role in billing and coding compliance, and enabling collaboration between all the players from providers to coders is key to optimizing billing and claims management, as well as care quality.
“We’ve got to collaborate, and we’ve got to use our technology to our advantage,” Owens concludes. “These strategies help make us more efficient, more productive, and use technology so we’re getting the best out of a tool that we can.”