5 steps to address the coding talent shortage in 2014 and 2015

 Physician groups, hospitals and coding support companies have been gearing up to address the many changes required to meet the challenges of the upcoming conversion to ICD-10-CM/PCS. A recent poll of both large and small providers shows that the successful organization will examine every department, and assign responsibility for every point of contact with three key functions:

  • Current ICD-9-CM code users in every department.
  • Clinical documentation trainers to address skills improvements in every person who charts the patient’s care.
  • Auditors who review both pre- and post-claim coding quality, and who work to resolve underlying issues. 

Here are five concepts that may increase the success rate in managing through this historic change in coding and reimbursement processes.

1. Centralizing control and delivery. Consider centralizing the key processes right now to ensure control over the ICD-10 change process. There are many end users of HIM coding throughout the organization, some owning only a part of the coding process. As providers struggle with increasing complexity (in both regulation and process) and decreasing reimbursement, it is critical not to expand coding functions piecemeal to address various interdepartmental issues. With almost 100 hospitals offering early retirement or termination to nearly 8,000 employees this year,1 managers will need to take a razor-sharp look at how to manage the many moving parts of ICD-10 conversion without adding more cost than is needed. 

2. Assess today's needs as well as future needs.  Review coding and CDI needs today to determine whether your organization requires some temporary or permanent outside help to ensure timely coding of all accounts. Carefully assess where you spend your payroll, and use the "80/20" or Pareto rule to ensure that your best resources are committed to the medical charts and patient accounts with the most exposure to your organization. Evaluate computer-assisted coding tools available in the market to determine whether they can help stabilize the work output. Where appropriate, identify and develop a trusted outsourcing relationship with a coding partner, either as a standing part of your coding strategy, or as an outlet to manage changes in patient volume, vacation time, and conversion backlogs. Assess which accounts (possibly the emergency department facility charges, outpatient diagnostic visits and hospital-based clinician charts) are more likely to be coded well by an outsourcing partner, and engage in that relationship wholeheartedly. Pay close attention to the many issues associated with ICD-10-PCS coding, which will have a significant impact on both revenue integrity and revenue recovery from payers.2

3. Establish baseline performance. Establish some key business analytics right now to ensure you have a clear understanding of your performance levels going into the conversion, as well as a solid baseline of clearly defined metrics. Some key values to track include trended case mix and payer mix indices; trended "top 100 diagnosis-related groups and ambulatory payment classifications" by payer, showing reimbursement amounts; and current trends in denials by payer, by service, by clinician.3 and by reason. It is also important to track absolute changes in reimbursement due to changes contained in the instructional guidelines within ICD-10. Examples of this include guidance that directs the coders to use a different primary diagnosis in ICD-10 versus ICD-9, or to exclude a diagnosis in ICD-10 that would correctly be included in ICD-9.4 Although these changes are projected to be small (about 0.5 percent of net revenues), a good mitigation strategy includes the analysis of pre- and post-conversion reimbursement.  

4. Build a team, not silos. The centralized approach to managing the transition will help build a seamless relationship with your IT, health information management and revenue cycle departments, so that all technology issues are reviewed by key players and are ready for conversion. IT's discipline and skills will help capture a higher percentage of interface issues across all departments and systems. The high-performing hospitals include every revenue cycle department in the conversion discussion, in management development and in the leadership process.5 Coordinating the efforts of the nurse auditors, case management, clinical documentation improvement and coders will ensure a higher rate of clean claims and optimal results from payers.

5. Build audit strengths. Don't underestimate the need for auditing resources before, during and after conversion. The auditors will review clinician documentation skills,6 manage ambiguously documented records, assess coding interpretation skills, and evaluate and respond to payer audits and denied claims. Starting well before the transition, high-performing hospitals will dual code charts and auditing results. During the transition, auditors will be committed full-time to internal audits of documentation skills, ambiguous charting and chart coding for reimbursement. Once claims are billed, auditors will be fully engaged with the revenue cycle leadership in addressing medical denials and underpayments. Each of these tasks will require significant efforts by highly trained and motivated staff. The alternative is for the healthcare organization to accept fewer claims paid in a timely manner, and fewer claims paid according to the level of service delivered.

Historically, our industry has not fared well during times of conversion. Even with careful planning and a delayed deadline, providers suffered financial harm from cash flow constrictions as a result of process failures in the HIPAA 5010 conversion.7 Even with many millions of dollars, the Patient Protection and Affordable Care Act IT teams at HealthCare.gov and in some of state-controlled exchanges faced teething problems. So, take a look at the five concepts listed here, and begin, or continue, to build strong organizational, intelligent and open processes to ensure a successful outcome in October 2015 and beyond.

Devendra Saharia is the CEO of AGS Health Inc. He can be reached at devendra.saharia@agshealth.com.

More articles on ICD-10:
A year away from ICD-10, what to do now to prepare
8 tips for ICD-10 preparation  
ICD-10 will lead to more domestic violence data

1 “91 Hospital and Health System Layoffs in 2014,” Dani Gordon, June 2014,  Becker’s Hospital Review

2 “Key Strategies for Ensuring Clinical Revenue Integrity with ICD10,” Angela Carmichael, MBA, RHIA, CDIP, CCS, CCS-P, and Melinda Tully, MSN, CCDS, CDIP, 2012,  AHIMA Presentation

3 “ICD-10 transition to impact specialists more negatively,” Kyle Murphy, PhD, May 2013, EHR Intelligence

4 Guidance directs coders to use neoplasms over other diseases, which will affect MS-DRG 812 (RBC disorders) in a patient with comorbidity with cancer, resulting in MS-DRG 842, as an example.  Likewise, exclusion of I46.9 (cardiac arrest) with I50.9 (heart failure) significantly impacts the weight of a DRG, especially when it is the only MCC.

5 “ICD10 Staffing Issues Extend Beyond Coding,” Elizabeth Stewart, RHIA, CCS, CRCA, 2014, ExecutiveInsight

“6 Tips of using CDI to drive RCM,” Kevin Fuller, July 2014, Healthcare Finance News

7 “ICD-10:  Avoiding the 5010 Pitfalls,” Holly Louie, CHBME, 2012, HBMA presentation to The National Committee on Vital and Health Statistics 

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