This blog post excerpts an article in the Q4 2015 issue of PX Adviser, our quarterly magazine designed to bring you thought leadership and best practices for improving the patient experience.
With the ICD-10 deadline just behind us, it is clear that ongoing competency maintenance and remediation will be key factors in optimizing the revenue cycle long term. We asked ICD-10 content expert Tom Ormondroyd, Vice President and General Manager, Precyse Learning Solutions, to share some words of wisdom on a successful transition. Starting with organization-wide buy-in, Ormondroyd outlines ways to ensure the best outcomes and avoid some of the worst consequences.
HealthStream: Now that healthcare organizations have made it over the initial ICD-10 hurdle, what is next? Is a maintenance of competence approach needed?
Ormondroyd: ICD-10 is not a quick sprint, but an ongoing journey until ICD-11. For this reason, we need to master our performance in ICD-10 to ensure appropriate payments, optimize documentation, and decrease compliance risk. Maintenance education and remediation are important for all employees engaged in the revenue cycle. Medical coders, for example, must sharpen their foundational skills not only in ICD-10, but also for CPT and other coding rules and systems. They must improve confidence in newer concepts such as ICD-10-PCS and hone their clinical acumen due to the specificity of the new codes. For physicians, improving documentation requires ongoing initiatives to ensure optimal documentation across the entire patient encounter. Case Managers and other care coordinators need to keep abreast of new issues and regulations impacted or related to ICD-10. If so, who needs this type of training? Anyone that was trained in ICD-10 initially needs to be part of this maintenance initiative. Yes, coders, billers, physicians, clinical documentation improvement specialists, case managers and others are most critical, but anyone who documents or supports the documentation of the medical record or interacts with an ICD-10 code should be part of this initiative.
HealthStream: Besides ICD-10, what other coding issues should healthcare organizations be concerned about?
Ormondroyd: Organizations have been so focused on ICD-10 that they have taken their eye off the ball on other coding issues that continue to wreak havoc in our industry. CPT still causes many challenges—not just for coders—but for many healthcare professionals. CPT is used far more often by non-coding individuals who have not been trained on its use, which is dangerous. But, systems like CPT and HCPCs continue into the world of ICD-10 and will draw added scrutiny as more specific ICD-10 codes will be required to show the medical necessity of the procedures, tests, and materials we use. We also need to be very aware of the many updates and changes that are made annually. CPT went through significant updates this past year, so we expect a very large update to ICD-10 once the code freeze is lifted. Also, there are others areas like modifiers, Evaluation and Management (E/M) levels/ codes, and code edits that are causing confusion and challenges. All of these areas are ones we should focus on. Lots of money is being left on the table for the tremendous patient care and services we provide, due to lack of understanding and training.
HealthStream: What suggestions do you have for healthcare organizations that are experiencing negative financial consequences due to the transition to ICD-10? What are the best steps they can take to improve their revenue cycle management?
Ormondroyd: You need to get to the bottom of why negative consequences are occurring, and you have to do it right away. There are many reasons why ICD-10 could cause a negative impact, but none are because of the system itself. Remember, ICD-10 provides far more choices to show the severity of our patients’ illnesses, so we cannot blame the system. In this way, there are several places they could look for deficiency, but three of the most likely offenders are the codes they select, the documentation they document, or the delays in their revenue cycle. If coding is inaccurate, incomplete, or not appropriate, then it is highly likely that the organization is leaving money on the table or increasing the likelihood of denials. To resolve this, have an external coding audit completed to see where your biggest issues reside or if certain coders need additional training. Use coding assessments to look directly at areas where the coders are struggling and attack those with education. If documentation is the challenge, then do the same thing—perform audits of your documentation to see if certain diagnoses or certain physicians are posing the problem or if the issue is widespread. If the problem is a delay in the revenue cycle, they need to check with the HIM leadership and find out whether the delay is due to decreased coding speed or if they are being held up due to lack of query responses or something else. Delays in the revenue cycle can cause significant cash impacts as more and more money is not billed, and of course, not paid.
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