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Coder Workflow in the ICD-10 world

July 3, 2012


Oct 1st, 2014 is a date when ICD-10 will go live. The ICD-10 code sets are not a simple update of the ICD-9 code set. They have fundamental changes in structure and concepts that make them very different from ICD-9. CMS reports the following benefits of converting to the ICD-10 coding system:

  • Improving payment systems and reimbursement accuracy 
  • Measuring the quality, safety and efficacy of care 
  • Conducting research, epidemiological studies, and clinical trials 
  • Setting health policy 
  • Monitoring resource utilization
  • Preventing and detecting healthcare fraud and abuse 

The conversion will allow for the accommodation of new procedures and technologies without disrupting the existing coding structure. This will allow for better, more accurate payment. With the greater detail of the ICD-10 coding system, claims will be clearer and the diagnosis more precise to substantiate medical necessity. This may decrease the cases in which medical records will need to be sent to support a claim, also decreasing adjudication time.

Today coders workflow runs very efficiently. But when codes incresaes from 13,000 to approximately 68,000. You can not assume that it will continue to be efficient once ICD-10 takes effect. Experts say the new coding system will pose new challenges, and it could also place significant strain on coding productivity if not addressed from a workflow standpoint.

But changing coder’s workflow process can have major implications on finances, and general operations. Assessing efficiency today to identify areas for future improvement allows organizations to better understand the factors they must consider to manage the change effectively.

If providers perform their gap analysis early on, they know all the work that needs to be done for the ICD-10 transition, and they can plan for it effectively. They have a lot more time to allocate resources.

The good news is that pushing the ICD-10 deadline back to October 1, 2014, provides providers the much-needed time to not only start a gap analysis but also perform a more thorough one. It also affords providers the opportunity to address staffing shortages that will likely occur due to attrition as well as evaluate technology solutions, such as remote coding options, that increase the likelihood of finding and retaining qualified staff.

To limit the negative effects of the ICD-10 transition, providers should take the following steps to address key aspects of coder workflow.

Take Documentation Into Account
Clinical documentation triggers a coder’s workflow, and in ICD-10, it must be extremely specific. Insufficient documentation will pose the largest disruption to workflow, particularly as coders familiarize themselves with ICD-10 coding requirements. The extent to which insufficient documentation will impact coders’ workflow will vary by provider depending on the coding staff’s clinical and coding knowledge, the electronic tools to which coders have access, and physicians’ overall cooperation and understanding of the requirements.

It’s helpful for physicians to understand high-level aspects of coders’ workflow so physicians are aware of what happens to the record directly after they document care. Having this understanding could make physicians more sensitive to coders’ needs.

However, it’s important to look at documentation from all sources, not only from physicians. This includes information that registration personnel collect on the front end, such as name, date of birth, insurance information, and reason for admission. It also includes data from outside organizations and entities that furnish prior or concurrent medical information. All these sources should be included in a gap analysis.

Given ICD-10’s anticipated impact on coding productivity providers should make time to assess their query process to minimize the number of times coders must look at each record. In particular, she recommends asking the following questions:

• Do coders query physicians manually or electronically?

• Can coders query directly from the EMR for greater efficiency?

• Do coders receive an alert to let them know that physicians have responded to queries?

Although it’s helpful to proactively evaluate and improve documentation and the query process, coders simply may not have the information they need to assign a code or they may have questions about how to assign it. Rather than allow queries to skyrocket or productivity to come to a halt, some providers are outsourcing a structured documentation process which may help them to answer coders specific questions that require coders to first refer to internal resources or use technological tools (eg, computer-assisted coding [CAC]) before approaching physicians or other staff members.

Evaluate Work Assignments
Most providers have already established a tried-and-true method for assigning work to coders. However, ICD-10 may prompt some coding managers to consider alternatives that can streamline efficiency and productivity. If providers lack internal resource on ICD-10 then looking to outsource right coding company early on would help them to build trust and relationship. That will help them greatly when ICD-10 will be implemented.

For example, assigning work based on a coder’s skill sets can be advantageous because it allows organizations to capitalize on employee strengths. Technology solutions are available that can automatically do this as well as track when certain coders—particularly remote or contract workers—are logged onto the system and available.

These solutions test coding skills using various patient types and combine this information with data gleaned from previous audits to create a profile for each individual. Then the system automatically routes certain cases (eg, interventional radiology) to the coders who can best handle them according to the information in their profiles.

Incorporate Prospective Auditing
If providers take Medicare patients, RAC Audits are here and it’s going to stay here. Although most internal auditing occurs retrospectively, providers may want to incorporate prospective auditing earlier in the workflow due to anticipated errors, particularly during the first six months after ICD-10 implementation. Technology can help, particularly in identifying cases that may be at risk of incorrect billing based on a coder’s skill set, the physician, or patient type. It’s also important to establish a quality assurance process that coders can rely on when they have questions about how to apply the new codes. 

Computer Assisted Coding (CAC) will be very helpful
When you look at going from 10,000 codes to 150,000-plus codes, a coder cannot possibly know and learn all of those codes. Even if your documentation is up to par, coders may still be overwhelmed at the sheer number of codes in ICD-10. CAC may help make the list of code choices more manageable, and it may also help boost coder confidence in assigning codes—both of which can have a positive effect on workflow.

Aside from CAC, providers should also consider other tools that would ease the burden on coders. These include computer-assisted physician documentation to help identify and rectify documentation insufficiencies as clinicians dictate into the EMR and tools that cross-walk codes from ICD-9 to ICD-10 to help coders better understand the translation.

Staffing Alternatives
Given the expected decrease in coding productivity, some providers are starting to develop relationships with companies that perform contract/temporary coding to maintain a smooth workflow during the transition. To accommodate for decreased productivity, some providers are choosing to determine in advance how many charts per day an outsourcing company will code. Providers should consider the possibility of having to add more staff once ICD-10 takes effect because there will be a change in the entire code set, we’re probably looking at an increased denial rate. It’s a matter of having increased staff on hand if that denial rate does go up.


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