You can’t achieve 95 percent risk adjustment coding accuracy without getting it right from the beginning. Are you following best practices to ensure accurate code capture, or is there room for improvement? This checklist will help you find out.
1. Develop a standard set of coding guidelines based on CMS and your own coding approach.
The Centers for Medicare & Medicaid Services (CMS), the International Classification of Diseases (ICD) book, and the American Hospital Association’s (AHA) Coding Clinic provide a wealth of information related to coding guidelines. However, they can’t account for every diagnosis scenario that a coder comes across in a medical record. To lessen confusion for your coders, agree ahead of time on your philosophy of diagnosis capture across the “gray” areas of coding guidelines, such as your approach to signatures, specific diagnoses, and code capture of certain chronic conditions, and the use of current patient medications as support for documented patient diagnoses. Document your coding guidelines and have them available for reference throughout the coding season.
2. Train your staff based on their roles using actual medical record examples.
Once the coding guidelines are documented, don’t assume that each of your coders will interpret those guidelines the same way. Deliver training sessions that are role-specific and include actual examples from medical records to drive deeper understanding of the coding concepts. Coding is equal parts art and science, which means the experience and perception of the coder can affect the results. Providing documentation related to common errors that occur in the coding process will foster greater consistency across your coders. Train by role so that all members of the coding team thoroughly understand their specific function in relation to diagnosis code capture. For example, a quality assurance (QA) specialist will benefit from training on how to research coding discrepancies that a team member performing first-pass coding would not. Keep in mind that people learn and retain information differently. Aural learners need to hear a concept several times before it sticks. Experiential learners need to code several records before understanding a concept. Visual learners do best when they can see examples.
3. Validate your coders’ understanding of the guidelines before they code any medical record in production.
It’s much easier to maintain coding accuracy if all coders have proven they understand the coding guidelines before they begin a project. And the best way to measure a new coder’s understanding is to assess their accuracy in a test environment before they begin working in a live production environment. Require 100 percent coding accuracy in the test environment and authenticate each coder’s understanding of the guidelines. Options for validating a coder’s understanding include one-on-one mentoring, 100 percent review of a defined number of coded charts, or collaboration with a QA specialist in a group training session while coding records together.
4. Create a coder reference checklist to use throughout the coding season.
A simple coding checklist provides a reminder of the key elements to consider when reviewing a medical record for diagnosis code capture. The checklist should be short and include items that are relevant to all records. For example, is the record for a single patient? Is this a face-to-face? Are the provider signature and credentials present? Is the diagnosis current? With enough repetition and reinforcement, the elements required to ensure coding accuracy become second nature.
5. Host a Q&A session a week after coding commences and have SMEs host desk reviews.
Many questions don’t surface until after a coder has begun working on a project. Having team members document questions and send them to a centralized team, such as the appointed training team, provides everyone with the opportunity to receive answers to their questions in real time and almost guarantees that errors will be fewer. In addition, giving team members face time with your subject matter experts (SMEs) to discuss coding questions builds confidence and lets your coders know that they have your support. The SME can use this time to address coding nuances and quality concerns, answer questions, and provide the reasoning for their coding determinations.
6. Monitor each coder’s accuracy at the project level and remediate staff that fall below 95 percent.
The Office of Inspector General (OIG) sets the bar for coding accuracy at 95 percent. Make sure you frequently monitor your coders’ accuracy to meet and exceed that bar. Providing immediate feedback during the first two weeks of a project will prevent little errors from becoming larger trends. If your coders are working on multiple projects, don’t assume that they are proficient across all projects because their aggregate coding accuracy is at 95 percent. Coders who do well in non-facility projects, such as those for a primary care physician (PCP) or specialist, often struggle in facility projects. Such difficulties can be masked if you just look at the coder’s summary performance level. Accuracy that falls below 95 percent may signify that a coder lacks the fundamental knowledge needed to be successful in a project when coding independently. These situations may call for the coder to be placed into remediation, in which a seasoned coder reviews 100 percent of his or her coded images for a set period of time or until accuracy has increased to at least 95 percent.
7. Use data to drive coding decisions, find error trends, and identify areas for targeted training.
Monitoring coding accuracy—whether via a system-generated report or a manually compiled spreadsheet—will enable you to spot error trends such as missed codes or codes that should not have been captured. Leverage data, such as the top ten missed diagnosis codes, to create targeted diagnosis trainings or to set up a secondary audit, which you can provide at the beginning of a project or throughout the season as needed. Recognizing errors, correcting those errors, and communicating across the team will go a long way toward safeguarding your coding accuracy.
8. Establish a discrepancy resolution process, a SME, and a coding advisory group to support coding consistency.
Coding discrepancies will always arise because guidelines are not always black and white, nor physician documentation optimal. However, certain approaches can foster greater consistency across coders. Assign an SME as the lead when a coding determination is required who is empowered to make that final decision. This can be a seasoned QA specialist, team lead, or someone on your training team. Another best practice is to develop a coding advisory group, staffed with a mix of coding and physician leadership, where members can research, discuss, and resolve coding questions, ultimately communicating determinations in writing across the coding team.