Making sure that an account has integrity from start to finish is not only ethical, it has a trickle-down impact to finance, decision-making, clinical protocols, research outcomes and external reporting.
Prior to internal and external entities scrutinizing individual codes and abstracted data, a healthcare system’s main inpatient coding quality focus may have been ensuring the DRG was right. If the DRG was correct, hospitals would get accurately paid by payers for the care provided, and high-level quality reporting was directionally accurate.
Organizations may include up to 25 diagnoses codes and 25 procedure codes per account. It’s not just about accuracy of the codes used for DRG classification — it is about complete, accurate and consistent coding as these codes are used for research, data analytics, state reporting, clinical registry reporting and population health, among other areas.
For example, consider mortality index ratings. Every hospital has to monitor this data and evaluate whether their mortality rate is higher than it should be or not appropriate based on its patient population. The DRG could be accurate, but if the organization did not identify that the patient was receiving palliative care and/or the palliative care code was not sequenced to the top 25 codes, it may impact observed-to-expected mortality.
Every code on the patient’s account needs to be represented accurately — it needs to correspond to the clinical documentation and have integrity.
How coding integrity came about
When the U.S. switched from ICD-9 to ICD-10, most hospitals believed they would see a dip in DRG coding accuracy rates in the 85%-87% range, which could result in huge revenue loss.
To remain ahead of the curve from a quality and education standpoint, organizations that trained medical coders and medical coding quality review personnel in advance were able to keep accounts moving, and when ICD-10 went live, overall DRG coding quality levels remained stable.
By outsourcing production coding, or “first touch” coding, to third-party companies, healthcare systems are able to devote more resources utilizing data science to review accounts that were flagged as having a potential coding or charging error. This allowed for limited resources to review the right charts versus casting a wider net and reviewing many accounts that were already accurate.
This was a major shift from an industry tendency to code accounts and directly submit them to payers, relying on retrospective coding reviews to identify any coding errors. Instead, hospitals could review accounts more than once prior to billing to ensure every code and corresponding charge was accurate prior to billing.
Therefore, hospitals may not use the term “coders” anymore. Many coders are not just coding; they are evaluating the integrity of the codes and abstracted data associated with each patient.
As systems begin to detect patterns and learn from previous patients’ charts, the philosophy of traditional production coding and retrospective auditing has shifted to evaluating the integrity of the codes and data prior to bill submission.
For example, consider a transcatheter aortic valve replacement (TAVR) patient. As a fairly new evolution to the way cardiologists and cardiovascular surgeons perform minimally invasive heart procedures, it is a high-dollar DRG and a high-dollar device procedure. If the organization newly implements a procedure at its facility, there would need to be processes put into place to ensure that each item associated with the TAVR is captured and that the facility is being paid appropriately and the codes accurately reflect the patient’s care.
With coding integrity, specialists can ensure that if a TAVR is coded, there is a device charge associated with the account in addition to a procedure code. And if it is not, an assignment can be put into place to flag every TAVR procedure to ensure charges line up. This may also work in reverse, if a TAVR charge is associated with the account but no corresponding procedure code is present, the account may be stopped before billing to ensure the appropriate procedure code is placed on the account.
The possibilities of workflows and assigned account reviews are endless to ensure code and charge accuracy, as well as coders’ abilities to translate clinical data to patient encounters so hospital records are up to date.
Making sure that an account has integrity from start to finish is not only ethical, it has a trickle-down impact to finance, decision-making, clinical protocols, research outcomes and external reporting. If an organization has multiple incorrectly coded accounts, it could lead to additional audits, compliance risks and fines.
Furthermore, it is important for an organization to ensure proper sequencing when reconciling and validating diagnosis for the respective DRG to provide accurate payments when a hospital’s patient population is comprised of more severely ill patients.
Historically, coding reconciliation follows the CMS standards for ensuring that the coded information matched the health record. CMS follows the Medicare Severity-DRG (MS-DRG) classifications that are predominately based on the following:
- The sequencing of the principal diagnosis
- The presence or absence of complications and/or comorbidities
- The presence of major complications or comorbidities
- The occurrence of a procedure(s)
- Patient gender and discharge disposition
Some states and payers are moving to an All Patient Refined DRG (APR-DRG) model, which was developed to further reflect complexity. It not only ranks the DRG but evaluates illness severity and mortality risk – two more levels to evaluate when ensuring code integrity.
Regardless which classification system is used, the key objective is to ensure that patient claims are supported by the actual clinical documentation and exact procedures and treatment performed. Having the documentation to support the claim is absolutely essential.
Coding integrity specialists go into the medical record to ensure that all clinical notes on patient charts match up to the assigned codes to represent the proper diagnosis and treatment.
Setting up routine monthly meetings between revenue integrity and coding integrity can help explain discrepancies between accounts and drilling down to see if charges were built incorrectly causing them to be associated with an incorrect code.
An example would be when patients show up in tracheotomy reviews when a charge was built for a trach-tube instead of a G-tube and should have been coded as a gastronomy patient. Revenue integrity and coding integrity would work together to ensure the process is updated and going forward, the correct codes match the correct charges.
Another example is when a patient was stabilized and transferred to another facility for a higher level of care. Because accurate coded data extends beyond diagnosis and procedure codes, coding integrity would partner with revenue integrity and case management to validate patient admission, discharge and transfer data that influence outcomes, such as where the patient was admitted from or discharged to (e.g., another acute care facility, skilled nursing facility, rehabilitation facility).
Building from the ground up
Coding integrity is an integral part of the revenue cycle and should align with an organization’s overall strategic mission. Determining where there are initial gaps in the integrity of coding will help decide where to focus efforts.
Traditionally, a coding integrity department is comprised of a coding integrity director, coding integrity managers, inpatient coding integrity specialists and outpatient coding integrity specialists.
The director typically reports to health information management. However, the director should have routine communications and interactions with the CFO, clinical documentation improvement leadership, chief medical officer and clinical leaders with responsibility for quality, clinical data abstraction and registries.
Employees should be trained, either through the American Health Information Management Association or another certified program on pharmacology, disease management and marrying clinical information to code assignment.
In addition, coders should have a Certified Coding Specialist (CCS) or Certified Coding Associate (CCA) credential — two of the most recognized certifications in the healthcare industry — each requiring 20 hours of annual education.
Continuing education is a critical component for a coding integrity department to stay current on updates, compliance rules and regulations. Narrowing down time every week for coders to discuss niche accounts and fine-tuning skills beyond preliminary reviews will set a team up for success in adherence to documentation
and validation guidelines.
In addition, a well-balanced coding quality review team that retrospectively reviews accounts processed by each coding integrity person on a monthly basis is key to identifying errors or opportunities to improve coding accuracy.
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