Over the last two decades, the revenue cycle and revenue capture have evolved dramatically. In the past, coding teams focused heavily on getting claims out the door.
Today, there is greater emphasis on the quality of patient information and care. The emergence of electronic medical records and the growing importance of healthcare quality measures have transformed the way coders do their work.
Becker's Hospital Review recently spoke with Jann Owens, revenue cycle content manager at St. Paul, Minn.-based 3M. She discussed how factors like automation and richer patient data are expanding the role of the coder. Healthcare organizations that embrace education, technology and holistic approaches to coding enjoy cleaner claims, higher levels of productivity and better patient information.
Coding: It's not just about payments anymore
"I've been in HIM [health information management] for over 20 years, and there have been many changes in the revenue cycle. We went through a period when coders only captured the codes that affected the DRG [diagnosis-related group]," Ms. Owens observed. “When a patient came in for an inpatient procedure, the coders coded the specific principal diagnosis, the secondary diagnoses and the procedures, etc. that impacted the DRG. On the outpatient side, coders coded the diagnoses that covered medical necessity. The focus was on getting the right payment.”
The world has changed. Coders today can no longer take a myopic view of patient information. Healthcare organizations must conform to additional measures like Hierarchical Condition Categories (HCCs), quality metrics and myriad other items including and within value-based purchasing. New state and national requirements are also shifting regularly. To ensure healthcare organizations capture the right measures in their systems, coders must be trained to code completely and correctly.
One organization Ms. Owens worked for discovered the hard way how important it is to look at the big picture. As the team was coding bowel resection procedures, coders accidentally miscoded part of the Procedure Coding System (PCS) code. It didn't impact the DRG, but it did affect certain quality measures, which had a negative impact on the facility's bottom line.
"The quality team asked the coders to review thousands of accounts and change the PCS code. In the old world, it wouldn't have mattered, but in today's world, that coding practice affected the bottom line in new, unanticipated ways,” explained Ms. Owens. “Coders can't worry only about the DRG or the APC [Ambulatory Payment Classification]; they have to take a holistic view."
The role of medical coders is evolving
The roles and responsibilities of medical coders often depend on the size of the organization they work in, as well as the clinical setting. Ms. Owens detailed two coder models based on her experience:
- Coding generalists. In small, acute care settings, coders typically wear many hats. They must know how to code for both inpatient and outpatient care, as well as handle auditing, billing and admitting.
Some larger health systems have also deployed "float coders" who can code multiple patient types. "This approach is beneficial for healthcare organizations because they can provide float coders a broad variety of work. It's also good for the coders because they don't feel pigeonholed into a particular specialty," Ms. Owens explained.
- Coding specialists. Physician practices and larger health systems may divide their coders by medical specialty, such as urology or surgery. Smaller niche facilities, like cardiology or orthopedic hospitals, also employ specialty coders, especially when they need to meet quality and other metrics.
Many healthcare organizations are also reexamining and redefining the role and support of coders, in light of ICD-10 (the 10th version of the World Health Organization's medical classification system) automation and organizational process improvement. Ms. Owens highlighted three examples:
- Documentation improvement specialists. ICD-10 requires healthcare organizations to include specific information in patients' electronic medical records, such as laterality, the mechanism of injury or the material needed for an implant. This level of detail is new for many organizations. In response, some have created documentation improvement specialist roles to work with EMR vendors and providers to get better information into the EMR. Coders are a good fit for this role. They have an excellent understanding of what providers do, as well as the documentation that's needed for billing and coding.
- Data analysts. EMRs and other information systems are automating some tasks previously completed by coders. As portions of their jobs become obsolete, coders could be redeployed as data analysts. They know what to look for in patient information, and they know when to ask questions if something looks abnormal.
- Coding support staff. Large, acute care systems may hire additional coding support staff to track down discharge summaries, clinical notes or physician information. This helps coders stay focused on their work, resulting in higher productivity levels and lower costs.
Best practices for optimizing the revenue cycle through coding
As healthcare policies and the healthcare landscape become more demanding, organizations can adopt several best practices to optimize the revenue cycle through coding:
- Remember that education is key. The best way to improve coders' performance is to provide them with regular audits and feedback. "If we code correctly, we have cleaner claims and less back-end work," Ms. Owens explained.
- Don't pigeonhole the coding staff. Don't underestimate the coders' ability to learn new things. If organizations pigeonhole coders in specific specialties, they often miss out on the benefits that come from knowledge of multiple disciplines.
- Look at more holistic coding practices. This helps everyone in the long run. Consider using technology tools to add secondary diagnoses that cover medical necessity and HCCs, as well as identify the nuances of PCS and Current Procedural Terminology (CPT®) codes. These tools improve productivity and provide a more comprehensive patient picture.
- Pay attention to the EMR. Copy and paste is out of control in many organizations. Coders often find many inconsistencies in the EMR. "We need to bring HIM back into the decision-making process for a lot of EMR issues. They understand health information and what's appropriate," said Ms. Owens.
Conclusion
As the healthcare sector changes, the coding function must evolve along with it. "We can't stay stuck in the past, doing what we've always done," Ms. Owens said. "We need to look for new approaches, and we must break down silos. It's through communication and teamwork with our peers in different areas that we'll be successful."