Ask Yourself These 3 Questions Before Your Next Coding Review
Now that it’s February, it’s not uncommon that many of us have completely abandoned our New Year’s resolutions. All those good intentions went down the drain during the first winter storm. Snow days were made for bingeing on junk food and Netflix, right?
But that’s no reason to descend into a shame spiral. Just because you’ve lost momentum doesn’t mean it’s too late to refocus and begin again. Enlist the help of an experienced coach to train, educate, and hold you accountable to ensure your success.
The same theory applies to coding reviews. You know they are necessary to improve the quality of your Coding Department. Perhaps you’ve intended to do another audit but get hung up on finding the time, the manpower, or how to get started. Jillian Poe Howitt, RHIT, CDIP, CCS, Review Services Manager at Health Information Associates sheds some light on how to prepare for a successful coding review.
So, you know you need a coding review – where do you start? Defining your goal should always be step one, but that’s not always cut and dry. The answer varies based on the objectives of your review.
We ask our client partners the following questions to help guide them on establishing their objectives:
- When was your last review?
- Are you seeing a drop in case mix, quality scores, or have you experienced an unexplained change in denials?
- Have you recently hired new coders?
It’s been awhile since my last review
Haven’t had a review in six months, two years or longer? Hey, it happens.
If this is the case, we recommend starting with a Baseline Audit with a random sample. This provides a snapshot of where you coders stand. It also allows you to see strengths and where opportunities lie in order to focus on education and future reviews.
Blindly jumping into a focused audit at this point could
a) provide great results, but make you question if that was the best use of limited funds, or more likely
b) provide results that make you fall out of your chair because the sample was ‘loaded.’
I’ve had my Baseline Review, now what?
Based on the results of the initial review, a thorough analysis of areas that fell below your expectations should be performed.
For instance, did specific DRG’s, Diagnosis, Procedures, MDC’s reveal a trend? Were there too many/too few queries, individual coders with less than stellar results?
For our client partners, we provide an Executive Summary. This report highlights areas of priority with action plans and modules and a series of follow up focused reviews to ensure the education has not only been planted, but that it’s taking roots.
It’s always ‘Coding’s Fault’
Is someone breathing down your neck because those Quality Measures aren’t where they need to be? Time for a Focused Review.
For our client partners, we identify a sample for an in-depth review to reveal the possible reasons behind the changes. There are other factors – in addition to coding – like 30 day Re-Admits, POO and excluded code lists that can affect quality measures. Of course, we’ll validate that these are being assigned correctly as well.
Is my New Hire up to speed?
Prebill reviews can save a lot of headaches if you don’t have the resources internally to audit a new coder. These provide the coder with immediate feedback and one on one education tailored to their individual needs and learning style.
Typically, this service is performed by dedicating one of our Interim Auditors to you for a specified period of time.
HIA’s comprehensive coding review service evaluates coding compliance and assists in identifying educational opportunities for coders, CDI specialists and providers. Our Comprehensive approach will also make certain that our clients are receiving appropriate reimbursement for each service rendered. Learn More »
In Part 5, we focused on identifying the approach being used for the spinal fusion. In Part 6, we are going to focus on identifying the type of bone graft used for the spinal fusion.
In Part 4, we focused on determining the spinal column being fused. In Part 5, we are going to focus on identifying what approach is being used to complete the spinal fusion (anterior, posterior or both).
This past year, HIA implemented “Buddy Up,” a program designed to help the new hire have a smooth transition into their new HIA roles with the assistance of a “buddy.” What is a Buddy? The Buddy is simply a peer who can guide the new hire in order to make them feel more comfortable. We are very proud of this program and have many success stories that we would like to share. Take a look at the wonderful feedback we have received below.
In Part 3, we focused on determining the level of the fusion(s) and how to determine the number of vertebrae fused. In Part 4, we are going to focus on identifying which column is being fused (anterior, posterior or both).
Part 3: Spinal Fusion Coding — Determine the Level(s) or Region of Fusion and Number of Vertebrae Fused
In Part 1, we learned the diagnoses associated with the need for spinal fusions, and in Part 2 the need to identify if the fusion is an initial or refusion of the vertebrae. In Part 3, we are going to focus on determining the level(s) of fusion, as well as the number of vertebrae fused.
In Part 2, we are going to look at the differences between initial fusion and a refusion. In ICD-9, there were specific codes to show if the fusion was an initial fusion, or if it was a refusion. In ICD-10-PCS, initial fusions and refusion procedures are coded to the same root operation “fusion.”
This is Part 1 of a 14 part series focusing on education for spinal fusions. Spinal fusion coding is a tough job for coders. There are so many diseases/disorders that result in the need for spinal fusion, and even more choices in reporting the ICD-10-PCS codes.
The official definition from the Centers for Medicare & Medicaid Services (CMS) states that a Medicare overpayment is a payment that exceeds amounts properly payable under Medicare statutes and regulations. When Medicare identifies an overpayment, the amount becomes a debt you owe the Federal government.
The question asked in a physician query may be the most important element of the document. Query questions need to be as simple and concise as possible. The physician should have no doubt what the coder is asking.
Coding complications of transplanted organs has always been a coding dilemma. With the implementation of ICD-10-CM that didn’t change. However, coders have multiple directives to help in determining what a complication of the transplant is vs. non-transplant conditions and diseases.
We interviewed our most productive coders, reviewers and members of our education team, asking them what steps they take to find a rhythm that works for them. This week, we talked with Beth Martilik, MA, RHIA, CDIP, CCS, Assistant Director of Education, about the steps she takes to find her routine.
With the implementation of ICD-10-CM came more codes for reporting many different conditions and diseases, and atrial fibrillation is one of those. For many years there was only one code available for reporting this condition, even when the physician further specified the type of atrial fibrillation that the patient had. In ICD-10-CM, there are four codes to report atrial fibrillation.
We have a case where the physician removes mucoid casts found during bronchoscopy. We have also seen mucus plugs removed during bronchoscopy. The MD performs bronchial washings then removes a large amount of tenacious and thick mucoid casts via bronchoscopy. Is this coded drainage, extirpation or excision? What body part is used?
The key to making the query process more efficient is to look for words or documentation while reviewing the record that may signal a potential query opportunity and to note the finding at that time. By the time a coder reaches the end of a record, documentation may have been found to eliminate the need for the query.
Question: This patient is noted to have “Lymphangitic carcinomatosis of lungs with mediastinal lymph nodes.” How would I code the diagnosis? Would I code metastatic cancer to the lung (C78.01) or metastatic cancer to the lymph nodes (C77.1)?
Coding these can be challenging for coders when trying to decipher the operative notes and terms that are used. The physicians are still using the terms excision and resection interchangeably and review of the entire operative note is required to select the appropriate root operation. Remember, it is the coder’s responsibility to determine the root operation based on the details from the physician in the operative report.
This would be considered a “mechanical” complication of the stent graft since the MD states it is a fracture of the endograft and it is folded over on itself. I would change T82.898A TO T82.598A for Other mechanical complication of other cardiac and vascular devices and implants, initial encounter. I did not use “displacement” because the surgeon did not state that the graft was displaced, only that it collapsed upon itself causing obstruction.
We interviewed our most productive coders and reviewers, asking them what steps they take to find a rhythm that works for them. This week, we talked with Valerie Abney, CDIP, RHIT, CCS, about the steps she takes to find her routine.
Osteoporosis alone is responsible for over a million fractures every year. Stress fractures are not as common but they do occur. There are more than 1 million total joint replacements in the U.S. each year, so there was a need to create codes for injuries that occur around or near the prosthesis. These are called “periprosthetic” fractures.
Back in April, the Office of the Inspector General (OIG) published a report detailing its findings from a review of two groups of high-risk diagnosis codes, acute stroke and major depressive disorder. The objective was to determine whether selected diagnosis codes submitted to the Centers for Medicare and Medicaid Services for use in CMS’s risk adjustment program complied with Federal requirements.
There seems to be differences of opinions on the issue of a 40w0day gestation Can you clarify if P08.21 should be assigned for 40w0day infant or if it would not be assigned unless the infant’s gestation age was 40w1day or greater?
Coders may find situations where a patient is documented as meeting SIRS or sepsis criteria, or has some clinical indicators reflective of possible sepsis, but the physician never documents sepsis as a diagnosis. Should the coder always query for sepsis in these instances?
In this example, would it be appropriate to code the complication code T82.03XA, Leakage of heart valve prosthesis, initial encounter as the principal diagnosis over the HFpEF (heart failure exacerbation) code?
A higher CMI corresponds to increased consumption of resources and increased cost of patient care, resulting in increased reimbursement to the facility from government and private payers, like CMS. We know that documentation directly impacts coding.
With the implementation of ICD-10-PCS more codes were developed in order to accurately report procedures. Spinal fusion coding is still a problematic coding issue and at times, even a coder’s nightmare. Coders often report only the code for the fusion thinking that one code would include all of the other procedures that are performed.
Answer: I would code 0HPT0NZ for removal of tissue expander from right breast, open and change 0HPT0JZ, removal of synthetic substitute from right breast, open, for removal of the acellular dermal matrix to 0HPT0KZ, Removal of nonautologous tissue substitute from right breast, open approach.
There are certain conditions that have instructional notes in the ICD-10-CM tabular/coding conventions that guide the coder in sequencing. This is especially true when the condition has a common manifestation or underlying conditions of a chronic disease. If there is a “code first” note in the tabular, the coder should follow this instruction and sequence the underlying etiology or chronic condition first followed by the manifestation as an additional diagnosis.
When it comes to coding and documentation, finding your own rhythm can lead to positive results. For our series, Find Your Routine, we interviewed our most productive coders and reviewers and asked them what steps they take to find a rhythm that works for them. This week, we talked with Meghan Schumacher, CPC, CPMA, Provider Coding Consultant at Health Information Associates, Inc., about the steps she takes to find her routine.
Last year, the Office of Inspector General (OIG) performed an investigation that found, “between 2014 and 2016, Medicare Advantage organizations overturned 75% of their preauthorization and payment denials upon appeal,” which is why, at HIA, we always advise our clients to engage in the appeals process.