By Dom Nicastro
Some say the holidays are a time for joy. Others find stress and chaos in the last six weeks of the year.
What do your coders feel as we wind down the year? It’s a good time to check their pulse if you’re an HIM manager or director—especially in light of ICD-10 implementation.
“Change is stressful on staffing,” says Darice Grzybowski, MA, RHIA, FAHIMA, president of HIM best practice consultancy HIMentors, based in Westchester, Illinois. “Many organizations lost key HIM coding staff prior to the ICD-10 go-live. Recruitment and retention strategies are key to maintaining a healthy revenue cycle process.”
Ask yourself if you have put in place specialized retention, recruitment, or incentive plans to keep coding and CDI staff happy and productive, Grzybowski adds.
HIM managers and directors can add these to-do items to their closing-out-2015 laundry list. How else can you tidy up the HIM ship as the end of the year nears? Coding experts told JustCoding that HIM directors and managers should also run a gap analysis of the ICD-10 early stages.
Are your coders happy?
This year is as good as any to recognize your coders’ hard work. They just underwent perhaps the most significant transition in their professional careers, ending a long journey of training, preparation, uncertainty, fear, and doubt. And that’s on top of their regular workload.
They want to feel appreciated more than ever, says Raemarie Jimenez, CPC, CPMA, CPC-I, CANPC, CRHC, vice president of training and education for Salt Lake City-based AAPC.
“You’ll want to reward your employees for the good work they’ve done throughout the year,” Jimenez says, “whether it’s a bonus or a personal gift from their manager. It’s good for them to know their manager took time to think of them, especially with the year they’ve had with ICD-10.”
Tell them you recognize the work it took on their part—the coordination, the training—to transition to ICD-10.
“Some people respond well to a handwritten thank-you note specific to them,” says Jimenez. “If everyone gets the same message, they may think this is one of those canned things. But if you do something unique for that individual, it goes a long way saying specifically what they did that year that you appreciated.”
ICD-10 has upped the stress levels significantly, Grzybowski says. Allow adequate time off—versus months of continuously mandated “overtime”—to reduce burnout.
“Salaries aren’t the only reason for change,” she says, “but not having regular feedback meetings, not having good equipment/resources, and not feeling involved in decisions plays a part. Of course, money and benefits and a flexible work schedule is important.”
Grzybowski works with hospitals to set up incentive coding plans and tiered coding career ladders to ensure diversity of work and bonuses for not only productivity, but also quality of work.
“Coders are the heart of hospital reimbursement,” she says, “and it’s critical to keep coders happy, educated, and productive members of the HIM team.”
ICD-10 checkpoint
Now is a good time to run an ICD-10 gap analysis, says Jimenez. Coding staffs went through a good amount of preparation for ICD-10. Revisit budgetary items. Did all your requests and expectations come to fruition?
“Now that we have implemented ICD-10, see if those plans are really meeting your business needs at this time,” Jimenez says.
Did you bring in additional staff? If not, will you need more now that you’ve got a good idea what it takes to get codes out in a typical week under ICD-10? If you’re managing an outpatient coding team, HCPCS and CPT® code changes will be important.
“Some HIM managers will be involved in reimbursement and billing,” Jimenez says. “They’ll have a general understanding and accounting of how codes impact revenue. Or it may be something that only the revenue cycle management team deals with. Depending on how involved with that you are, it’s important for managers to understand the (OPPS and IPPS) final rules and how it impacts facilities.”
HIM directors and managers can now see payments coming in from ICD-10 and recognize where the problem areas are.
“Everyone was preparing for doomsday,” Jimenez says, “and we’ve seen ICD-10’s not been as problematic as we were all led to believe. It didn’t live up to its hype. But it’s good to evaluate your wins and misses and quickly make up your misses.”
Something missing?
Grzybowski already does see some issues with ICD-10 coding in terms of data integrity, especially in physician or clinic billing.
Although ICD-10 codes were just implemented October 1, she agrees it’s not too early to audit and see how accurately you are assigning and capturing the correct codes.
Grzybowski says she’s seen a lot of missed opportunities—though they may be invisible because the codes still get paid and processed without error. However, they’re highly inaccurate due to omissions and lack of specificity in coding. This is especially true, she says, in the physician clinic area.
“Ask yourself if you have a trusted coding/[clinical documentation improvement] audit partner in place who can work with you to help educate staff and physicians and get to the root cause of problems in coding workflow,” Grzybowski says.
Were these problems already evident in ICD-9-CM?
Not really, Grzybowski says, because “the specificity wasn’t there.”
“Now,” she adds, “you can identify, for instance, whether this was an initial treatment for a specific diagnosis, or a subsequent visit, or dealing with the sequelae by a doctor. If the physician’s office is not taking care to include the seventh character correctly, this can impact insurance coverage for injuries or rehab care, etc.”
Another example is using incorrect coding guidelines. A doctor orders an MRI because the patient had a dizzy spell and facial numbness. The correct diagnoses on the initial visit are the dizziness and facial numbness (symptom codes). The doctor may have ordered the MRI to rule out a stroke.
“However if the billing service codes ‘stroke’ as the diagnosis—as opposed to the symptoms of the dizziness and numbness—and then the MRI is negative, there could be a medical necessity denial problem,” Grzybowski says. “Symptom codes are always to be billed for outpatient care unless the diagnosis is definitive.”
Educate—then educate some more
It’s up to HIM directors and managers to take the lead on this through education and auditing. A doctor’s office may be the facility at the most risk compliance-wise, Grzybowski says, if they have hired a billing/coding service that is not following guidelines.
“The scariest thing I hear is when coders or a billing company say, ‘We just code what the doctor tell us to or whatever is on the report that comes out of the [electronic medical record],’” Grzybowski says. “It is evident that poorly designed crosswalks are putting out inappropriate codes that do not distinguish symptoms from rule-out conditions and are using erroneous codes due to misinterpretation of coding guidelines.”
She predicts we’ll see more cases audited, problematic insurance company reimbursement, or post-payment takebacks because of this issue.
“So when people say it’s ‘calm’ post-ICD-10,” Grzybowski says, “I don’t think we have even started to see some of this fallout, and may not for a good number of months, or even a year from now. The important thing is to audit and then educate, and make change happen for compliance.”
Email your questions to editor Steven Andrews at [email protected].