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Solutions for Clinical Documentation and Coding Complexity

Revint Solutions for Clinical Documentation and Coding Complexity
As coding complexity grows, clinical documentation precision and review factors play into revenue recovery more heavily.

Policies, economics, and ethics all factor strongly into healthcare documentation solutions. As revenue cycle teams continually encounter clinical documentation and coding complexities, not only are professional coders scrambling to keep up, but revenue cycle teams are looking for better ways to recoup lost revenue in this time of constant change.

In an overview post at ICD10 Monitor, a number of great references are listed followed by this observation:

“What will the next generation of clinical documentation and coding look like, and how will it be achieved? Those questions are ones we all should be thinking about and trying to find answers for. Certainly, compliant technology will remain a part of innovation and solutions in the future. We see advantages to using the electronic health record that can be leveraged to improve clinical documentation and ultimately coding; just the mere fact that documentation is electronic and not written is a huge benefit to the healthcare system as a whole. Any foundation needs to be strong in order to last.”

Most likely, the next generation solutions will include a healthy look at infrastructure — software, departments, and personnel. Medical Economics puts it like this, “… with the preponderance of recovery audit contractor (RAC) audits, complexity of ICD-10 coding, and changes in payer reimbursement policies, many organizations are now realizing the importance of enhancing their coding infrastructure to ensure success.”

The American Academy of Professional Coders (AAPC) has a good definition of the moving target for clinical documentation and coding: “Clinical documentation improvement (CDI) is a process that continually seeks to answer, ‘How best can you maximize the integrity of the medical record?’ Although the goal of CDI is always the same—to provide a complete and accurate picture of a patient’s medical condition(s) and the care they receive—the means to achieve that goal are often specific to the environment (e.g., office vs. facility).”

We like the focus on improvement and find this requirement playing out in different scenarios across our solutions for hospital and clinical clients.

Often, clinical documentation and coding errors crop up during the DRG — Diagnosis-Related Group — validation efforts, which is why we have a service solution for this crucial effort. At the HIMSS19 conference this past February, James Grana, Ph.D., Chief Analytics Officer, and Bala Hota, MD, VP, Rush University Medical Center, presented the following common errors (see this PDF of their presentation):

  • Missed diagnoses
  • Failing to document/bill for an unresolved condition present in a previous calendar year
  • Using a “history of” diagnosis when a condition is actively occurring and not yet resolved
  • Using a generalized or non-specific diagnosis code
  • Failing to document completion of medication list review

The results of the steps taken to solve these common errors resulted in both reputational (made US News’ best hospital’s list) and financial rewards for the medical center.

So, the reward is clear when organizations address errors. However, each healthcare system can find themselves with different kinds of challenges. As the Medical Economics article observes, “The coding process is no easy task—there are more than 8,000 CPT codes and 69,000 ICD-10 diagnosis codes to choose from, as well as a litany of complex payer and regulatory guidelines to follow, in order to code accurately. Moreover, organizations utilize a wide array of resources and workflows to complete the coding process. Some require providers to select codes via an EHR or encounter form, while others utilize support staff to abstract directly from the medical record, and each approach has its own benefits and drawbacks.”

Then there’s the governmental policy audits and ethics factors. Just one example of this appears in an HHS (Health and Human Services) OIG (Office of Inspector General) compliance program for hospitals PDF.  Among other concerns, the guidance addresses “DRG creep” — “the practice of billing using a Diagnosis Related Group (DRG) code that provides a higher payment rate than the DRG code that accurately reflects the service furnished to the patient.” That PDF also indicates that the government is finding duplicate claims, “upcoding” in general, and that some hospitals may be providing medically unnecessary services. That’s a lot of moving parts to track. Again, the Medical Economic’s editors address this concisely: “High-performing organizations maintain coding and compliance programs that appropriately balance revenue maximization, coding compliance, and costs to ensure each visit is coded for optimal reimbursement.”

Revint takes a comprehensive approach with a combination of industry experts and leading edge technology, which enables our provider clients to deal with the constant updates, different payer contracts, and government policies needed for being paid appropriately. We provide organizations with additional benefits such as streamlined processes with greater efficiencies, enhanced CMS interface capabilities, enhanced reporting, and improved benchmarking capabilities with trending insights.