Make ICD-10-PCS training a priority in the New Year

By Mike Evans, RHIA, CCS, vice president of coding and compliance at In Record Time, Inc.

Coders are among the busiest employees in any hospital nationwide. However, they must make time to practice using ICD-10 even despite strict productivity requirements. In particular, practicing ICD-10-PCS will be critical as the industry heads into 2015. 

ICD-10-PCS is far more complex than the ICD-9-CM procedure coding system to which today’s inpatient coders are accustomed. In PCS, coders must be able to complete a seven digit alphanumeric formula. If they’re unable to assign even one character in the formula, they’ll be unable to assign the entire code. 

Experts agree that without critical details in the documentation, coders may default to non-specific codes. This is certainly not the intent of the more specific PCS coding system. It’s in coders’ best interests to practice using PCS as much as possible between now and October 1, 2015.

Where should coders focus their ICD-10-PCS training efforts? One of the most difficult aspects of ICD-10-PCS may be assignment of the root operation. For this reason, coders may want to devote significant time in this area. Identifying an improper root operation can lead coders down a completely incorrect path to code assignment. Incorrect code assignment ultimately jeopardizes both reimbursement and data integrity.

Coders should also spend the majority of their time practicing more complex cases, such as CABG procedures, OB/GYN procedures, orthopedic surgeries, and neurosurgical cases. These procedures are the ones that will likely cause bottlenecks in terms of productivity. Some of these procedures may even require more than one PCS code to fully capture the entire operation the physician performs. 

Another approach is to focus on high-volume procedures; however, keep in mind that these procedures may not be the most complex and therefore time-consuming.

Once coders have mastered root operation definitions, focus on whether coders can translate clinical terminology to a specific PCS operation. Physicians are not expected to make this translation. The 2015 ICD-10-PCS Official Guidelines for Coding and Reporting state the following:

 It is the coder’s responsibility to determine what the documentation in the medical record equates to in the PCS definitions. The physician is not expected to use the terms used in PCS code descriptions, nor is the coder required to query the physician when the correlation between the documentation and the defined PCS terms is clear.

How can coders work with medical staff to practice ICD-10-PCS? Ask medical staff members to identify the top 10 most complex procedures that they perform. Also inquire whether physicians would be willing to walk coders through the steps they take during each of these procedures. This can help coders visualize the procedure when coding.

Physicians should have already begun to document the additional details necessary for ICD-10-PCS, such as anatomical specificity and laterality. When physicians document these details, not only are they practicing good habits, but they’re also making records more helpful for coders who will use de-identified versions for practice purposes. If these details are missing from the record, coders have no choice but to assign an unspecified code.

Why is it important to audit for quality? Even when coders practice ICD-10-PCS on a daily basis, they’re still bound to make mistakes. Quality monitoring is critical, both now and once the new coding system takes effect. As coders practice using PCS, ensure that a manager verifies their work. When questions or discrepancies arise, address these topics during coding staff meetings. Develop internal coding guidelines to identify how coders will tackle certain procedures in lieu of updated Coding Clinic references.

How can organizations make coder training in general a priority? Unfortunately, training and education budgets are often among the first to be reduced or cut entirely when organizations seek to reduce operating costs. Coding managers and HIM directors must work with hospital executives to explain the importance of ICD-10 and the role it plays in the overall financial viability for the organization. As was the case with the transition to DRGs in the early 1980s—as well as MS-DRGs in 2007—organizations likely won’t realize the true impact of ICD-10 until after implementation. We shouldn’t let history repeat itself. Investing in up-front coder training will mitigate the impact of the new coding system as much as possible.

Avoid these mistakes when conducting internal coding audits

By Mike Evans, RHIA, CCS, vice president of coding and compliance at In Record Time, Inc.

Internal coding audits have always been important. However, as third-party auditors continue to scrutinize documentation and coding practices, it’s more important than ever to ensure that these audits occur regularly and that they’re effective. All too often, internal auditors overlook critical aspects of the audit, resulting in skewed data that may not paint a clear picture of trends and patterns. Even when conducted properly, audits may not yield results that are truly useful to the organization.

Following are some of the most common mistakes that internal coding managers and/or HIM directors make when conducting internal coding audits.

1. Audits are too narrow. Internal managers sometimes approach an audit with an agenda to increase CC or MCC capture. When organizations narrow their focus in this way, they may miss out on other problems within the documentation or coding. Instead, organizations should focus audits on documentation integrity—not simply identifying missing elements that would have increased reimbursement. Ideally, audits should ensure the following:

·     Multiple CC and MCC capture, when appropriate. Capturing only one single CC or MCC may not be sufficient in terms of ensuring a correct severity of illness (SOI) or risk of mortality (ROM). SOI and ROM both affect the observed vs. expected death rate—an important indicator of the quality of care provided.

·     Correct POA indicator assignment. This plays an important role in patient safety indicator (PSI) scores. An inflated POA indicator rate could inflate the PSI rate as well.

·     Compliant complication reporting. Physicians are hesitant to label complications as such; however, organizations need to encourage physicians to document complications when they occur. Reiterate to physicians that complications that occur intra-operatively are generally not the fault of the physician, but rather they’re due to a problem with the patient’s own health circumstances.

2. Audits don’t look beyond the organization’s own walls. One of the biggest mistakes that organizations make is not looking at how their data compares with other facilities in the state, region, or nationwide. Knowing how your organization compares with its peers is important because patients have access to this data that is reported on an aggregate level to various state health agencies. Sites such as Physician Compare and Hospital Compare make it very easy for consumers to shop around for the best quality care. Organizations need to know how they stack up against other facilities so they can take steps to improve data quality and public perception.

Knowing how the organization compares with others is also important in terms of gauging vulnerability for external audits. The Program for Evaluating Payment Patterns Electronic Report (PEPPER) is a helpful resource that provides hospital-specific data statistics for improper payment targets. Organizations can use PEPPER to compare their data other hospitals or facilities in the state, specific Medicare Administrative Contractor (MAC) jurisdiction and the nation.

3. Auditors don’t look for the story behind the numbers. Internal auditors may not look for the root cause of audit results. Instead, they must simply assume that the results are based on incorrect coding. However, the trigger may be something process-related and/or entirely unrelated to coding. For example, if the organization’s procedure is to require coders to code without the discharge summary, this might affect a coder’s ability to capture the principal diagnosis correctly. Consider a transient ischemic attack (TIA). When a physician documents both a TIA and a cardiovascular accident (CVA) throughout the record—but doesn’t rule out the CVA until the discharge summary—how can the coder truly know what proper principal diagnosis to report?

Another example relates to septicemia vs. urinary tract infection (UTI). Are coders required to query when the record is unclear? Are they given sufficient time to do so? If not, unclear documentation could lead to an unusually high rate of septicemia that could appear quite alarming during an audit.

Other root causes could relate to insufficient physician documentation, EHR glitches, etc.

4. Auditors don’t use updated resources. It’s a full-time job to keep up with ever-changing audit targets and requirements. However, using outdated resources and references can provide skewed audit results. Be sure to use updated coding guidelines and updated insurer policies. The Recovery Auditor FY2013 Report to Congress and FY 2015 OIG Work Plan are also good references in terms of structuring an audit and keeping updated on the latest targets.

5. No follow-up education is provided. After the conclusion of an internal audit, provide audit results to coders, physician advisors, and CDI specialists. Include a physician advisor when providing education to physicians, as they generally respond more positively when receiving information from a peer.

6. Organizations don’t perform follow-up audits. Perform an audit six months after concluding the original audit. This ensures the efficacy of any steps taken to rectify problems identified during the first audit.

How an external vendor can help

External coding vendors provide an unbiased look at an organization’s data. These auditors don’t have an agenda, and they also have no connection to the data. They often provide the impartial analysis that organizations need.

In addition, external vendors can perform the type of in-depth data analysis necessary to compare an organization’s performance (i.e., its DRG and APC mix) with similar facilities on a city, state, regional, or national level. Many external auditors work with clients nationwide, meaning they bring a wealth of knowledge and experience to the table. Organizations benefit from this bird’s-eye view of what’s going on in the industry in terms of third-party auditor trends.