ED. NOTE:

This is the first of a three-part series designed to compare and contrast the current and future states of coding and the coding manager's roles and responsibilities. The article below summarizes the movement from a retrospective review process to a prebill, concurrent review process that includes medical necessity, clinical documentation improvement (CDI), and coding.

Today's coding "world" tends to be focused on quality and productivity, based on audits of individual records and the number of records coded. The future promises a move from the traditional coding manager to an "integrated-state" data manager, with the goal being to reduce financial risk and increase data integrity.

Like many other industries, today's healthcare system is filled with prospective controls. The majority — infection control, medical error management, fall prevention, and safety — are directly connected to patient care and employee safety.

All prospective-control programs have one thing in common: Hospital staff anticipate or expect the errors based on past history. They have set up processes and training to prevent future errors, and if they do occur, established protocols quickly respond to the error. Staff track and trend all errors and utilize quality-improvement plans to decrease error rates and liabilities related to patient care and employee safety.

Hospital managers need to ask questions like the following: What prospective controls do we have in place to ensure correct payment? Does our facility have a "pay it right" program in place that is clearly evident to all employees? Does the program include quality-improvement plans and dedicated education to teach compliant billing and reimbursement practice to employees?

This article will identify some prospective controls that may be implemented to answer these questions with a focus upon medical necessity, documentation, and the coding process to ensure correct payment.

Current Coding State

At the present time, the primary focus is on coding productivity and accounts receivable. Controls integrated into coding processes are limited due to the priority of "dropping bills" and meeting unbilled day targets. Oftentimes, these controls delay the coding or billing process. Therefore, they are limited for the sake of productivity-a fact that has the tendency to increase financial exposure and decrease data integrity.

Common controls may include the following:

Concurrent (in-house queries during hospital stay):

• A clinical documentation improvement (CDI) program that integrates concurrent queries, increases reimbursement and avoids delays of post-discharge queries is in place.

Prebill (queries post-discharge [but before billing])t;/h4>

• Second-level reviewer (referred to another coder for confirmation of code assignments) is employed for any cases with one or no major complications and/or co-morbidities (MCCs) and one or no complications and/or co-morbidities (CCs).
• Coders validate and enter the final discharge disposition.
• Post-discharge queries occur until a response is received.
• A hold is in place for receipt of the operative note, pathology report, discharge summary, or other key documents.

 

Integrated State

The primary focus is on prebilling and concurrent quality documentation with an integrated approach. Controls apply to all parties who have an effect on documentation, coding, and bill submission, including utilization management. These prospective controls reduce financial exposure and increase data integrity and, therefore, protect revenue.

Concurrent (during hospital stay)

• Use CDI program to integrate in-house queries focused on achieving correct reimbursement, avoiding delays, and post-discharge queries.
  • Evaluate complete documentation for MCC and CC data capture.
  • Implement prospective control for coding and billing.
  • Evaluate appropriateness and completeness of documentation for principal diagnosis assignment.
  • Expand CDI to include responsibilities related to controls to avoid financial exposure.
  • Validate appropriateness and completeness of the admission order for the setting (inpatient versus observation or outpatient versus outpatient).

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