Tuning up the Revenue Cycle and Medical staff for the ICD-10 Transition Through Outsourced Coding/Auditing

We are recommending to our clients, especially those whose reimbursement and revenues have declined, that they take decisive action to both stem the bleeding and focus on improvements. HSMN’s advice has appeared in a number of articles since last fall.  Essentially they can be summarized as follows:

  • Do not rely only on the “Systems” and the “Black Boxes” that vendors will imply can solve all transition problems.
  • Revenue cycle managers must go to the source to encounter information which means the medical staff and their clinical documentation behaviors.
  • It is clear to HSMN that many hospitals are counting on the training of coders and new software to get them through the transition.Here is a News Flash!  No system or software can transition anything because there is no one to one correspondence between ICD-9 and ICD 10 especially when it comes to documenting and coding procedures.
  • Therefore, a fresh, dynamic interactive approach is essential and it includes the following:

o   An analysis of how physicians in all disciplines are now documenting to support their diagnoses and procedures.

o   A full assessment of where revenue is lost or claims rejected based upon clinical data, documentation and coding.

o   Using such data to work closely with the medical staff on a case by case basis to help them see what is required to be successful in the ICD 10 world for both the hospitals and professional fees.

o   Reconstructing current individual cases based upon the trending of data that reveals the gaps. For one of HSMN’s Academic Medical Centers almost 80% of rejected claims in the Epic System had lack of proper documentation for a diagnosis or procedure.

HSMN’s recommendation is to outsource some current coding and older cases to a firm that can provide a detailed analysis of the issues in the documentation and the physicians’ understanding of the coding.  The firm chosen must have excellent credentials and coders who are considered auditors and teachers.  This provides the internal staff some space and time for training and to better understand what they need from the medical staff.

Finally, after the audit or coding outsource is complete, the report on trends should be used to form teams consisting of key clinical champions and the best coders on staff to begin interacting with the medical staff on clinical documentation and coding issues.  In a recent article we pointed out that CMS is going to heavily scrutinize the use of “Smart Phrases” which some will try to build in to the EMR’s. The analysis suggested by HSMN will help support the changes needed to avoid such scrutiny.

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