Every inpatient discharge represents a check that a healthcare provider writes itself with inpatient coding serving as the pen. This simple statement doesn’t capture how to ensure the pen functions optimally or the check’s amount is accurate. DRG variances that coding inaccuracies cause result in hundreds to tens of thousands of dollars in unrealized revenue on an individual discharge. When considering all a provider’s inpatient discharges paid on DRG, this represents a significant financial red flag that cannot be ignored.
Background
According to an AHIMA practice brief, 95% is the benchmark for coding accuracy that provider organizations should strive for. Provider organizations come in all shapes and sizes, from large, multi-facility systems shaped by M&A activity to community hospitals. Some exceed this benchmark and some struggle to attain it. But regardless of size or location, organizations have an accuracy gap to fill. This gap typically represents millions of dollars of unrealized revenue. Understanding the root causes is vital.
Challenges
Healthcare providers face numerous challenges and competing priorities when they try to ensure coding and DRG accuracy:
- DNFB and coder productivity: Speed and accuracy do not complement each other. DNFB pressures inpatient coders to abstract accounts quickly, often at the expense of accuracy. Productivity metrics can encourage behaviors that compromise accuracy.
- Resourcing: Resources are finite. Hospitals rightly prioritize clinical investments over administrative. As a consequence, inpatient coding must do more with the same amount of resources, or in some cases, more with less. Due to the advanced nature of the skill set, demand for quality inpatient coders is high. Recruiting, retaining and training for this work can be difficult.
- Technology limitations: Front-end coding technologies like CAC have become ubiquitous. While these technologies have merits, they are not infallible. Common CAC sequencing errors can significantly impact the DRG and reimbursement. Supporting technologies can also be slow to update with annual changes to standard coding practices.
- Documentation: Physicians can be inconsistent in the depth and breadth of the documentation they provide for the record. Inpatient coders cannot interpret and must use the retrospective query process judiciously, if it exists.
- Industry change: The transition from ICD-9 to ICD-10 represented a 10x increase in code volume. This complexity has continued to impact coding and DRG accuracy, even several years after the transition.
- Opportunity cost: Investing human capital to increase coding accuracy often involves trade-offs. Organizations often tap experienced coders as an internal auditing layer to provide education and accuracy assurance. Using them in this capacity has merits, but the backfill of less experienced resources can temporarily affect accuracy. Internal efforts are only as good as the methods used to select records for auditing.
Insights
Organizations that are the very best at addressing these challenges are the ones that use a multi-disciplinary approach, combining both human and technology resources. Some elements of a successful approach to ensuring coding and DRG accuracy include:
- Education: Establishing a culture of education is important. Help coders understand that education efforts support their development. Education programs should be separate from the employee evaluation process and not be punitive in nature. Identify areas of focus, leverage experienced team members as educators, and cascade relevant information broadly and repeatedly across the team. Education is a discipline, not an event.
- Collaboration: Remove the siloes that often define clinical documentation functions. Ideally, physicians, clinical documentation professionals and inpatient coders should work in concert. Establishing physician champion relationships and joint CDI/coding meetings to discuss trends can help reduce the silo effect.
- Shine light on assumptions: Understand the written and unwritten rules that influence how coding teams function and pressure test their consistency with organizational goals. Know where coders deviate from industry standards and why. If there is a quality over reimbursement initiative, make sure the standards associated with that initiative are widely understood across the various teams.
- Utilize safety net technologies: Front-end technologies such as CAC are common. End-of-process technologies to catch variances post-code complete are less common but can provide both additional reimbursement and valuable inputs into the education process.
Summary
Inpatient coding teams get it right most of the time. It can be easy to lose sight of this given the impact of coding and DRG inaccuracy. Recognizing that fault does not reside solely with the coders themselves but is a consequence of the environment is an important first step to addressing the accuracy gap. Second, solicit feedback. Understand the specific challenges coders see as barriers to optimizing accuracy. Third, plan for and implement a multi-pronged approach based on coder feedback and these recommendations. Organizations that invest appropriately to put their teams in a position to be successful are more likely to reduce the accuracy gap and optimize reimbursement.
