by Julia Hammerman, Director of Education and Compliance, and Sam Champagnie, Senior Director, HIM Operations
The newness and specificity of ICD-10 ushered in a stronger focus on clinical coding audits. From internal reviews to external coding audits, healthcare organizations nationwide are revisiting tried-and-true audit practices with ICD-10 coding quality in mind. Diagnosis-related group (DRG) validation audits under ICD-10 have also become more strategic to realize revenue cycle success.
Audit focus different for ICD-10
Coding audit best practices shifted following the implementation of ICD-10. Since all coding stakeholders were comfortable with ICD-9 and needed to maximize HIM budgets, audits were primarily focused on targeted DRGs versus overall coding compliance reviews. With ICD-10, these coding realities and thought processes have changed.
It is now clear that more frequent audits identify the root causes of coding errors before they become ingrained coder habits. The financial impact of more frequent audits has been demonstrated and can be quantified to deliver a positive return on investment. This is accomplished by assessing coder competency, measuring code quality, and showing how missed errors can have negative effects on an organization’s bottom line. Under ICD-10, coding audits have evolved from an HIM line item expense to proven revenue cycle cost savings.
Specific areas of error, inaccuracies, and trends
Coders prepared and trained for ICD-10 under the initial set of coding guidelines. However, in October 2016 the guidelines were updated, adding more complexity to the coding process. Coders still struggle with putting the most recent guidelines into practice.
The most common areas for ICD-10 coding errors identified through coding audits include:
- Coding to the greatest degree of specificity
- Combination diagnosis codes and linked diagnoses
- Complex cardiac surgeries
- Correct interpretation of coding guidelines
- Identifying appropriate root operations
- Spinal surgeries
Based on these common errors, a combination of random and focused coding audits has become industry best practice.
Random sampling augmented by focused audits yields best results
Developing an audit program that includes a balance of random sampling and focused auditing delivers greater insight into coder performance under ICD-10. A methodology that begins with the random sampling approach pays great dividends.
Random sampling is effective in validating the current performance across an entire organization. It exposes previously unknown coding challenges and provides a practical way to assess performance at the individual coder level. This approach ensures each coder has a random sample of charts audited on a frequent, consistent basis—ideally monthly, or quarterly at a minimum.
When random sampling results are aggregated, HIM directors gain a clear understanding of the entire organization’s performance and can begin to identify opportunities for education and coding improvement.
The random sampling approach should then be augmented with focused auditing of target areas. The combination ensures a thorough understanding of error patterns and high-risk diagnoses, procedures, or service lines.
For example, after conducting education, review all charts coded in targeted areas for 30 days following coder training. This targeted audit pinpoints which coders responded to the education and which ones need another round. It also shows areas of opportunity that might not have surfaced during the random review.
Data analysis from the focused audit can be used to fine-tune coder training for the entire group or individual staff. For instance, we know coders are making errors in spinal surgeries, cardiac surgeries, and respiratory diseases, so those areas should be included in focused audits.
The combination of random review data and focused audit results builds a solid baseline of coding accuracy for the organization and for individual coders on DRGs, procedures, diagnoses, present on admission status, APCs, and CPT® code assignment.
Prompt one-on-one coding education important
Another important shift in ICD-10 coding audits is the need for faster and more frequent one-on-one coding education. Auditors must be able to quickly interact with coders to share results while also providing education. Prompt feedback to coders yields better results.
However, there are two common coding education challenges. Many organizations lack the management discipline and budgetary commitment to perform training immediately after coding audits. And, trainers aren’t always effective in delivering education based on individual coder preferences. A given educational plan might suit Coder A better than Coder B.
Four tactics to advance coding audits
Healthcare organizations invested significant resources on the journey to ICD-10. Now they must begin to recoup that investment. One way to do so is to revamp coding audit practices. In addition to greater frequency and a blended review approach, the following four tactics are suggested to turn audits into a positive financial endeavor versus a check-the-box compliance exercise:
- Know your training platform and content. If organizations are using a training platform or system as the primary education tool, trainers must know the material inside and out. This helps trainers guide coders to the correct resources and learning modules to make ICD-10 improvements.
- Focus on every code. Not every coding error impacts the DRG, not even in ICD-10-PCS. Auditors should focus on every code, regardless of its DRG impact, so coders can truly master ICD-10.
- Combine audits and education. Coding audits shouldn’t stop short of getting organizations where they need to be in terms of coding education. Auditing and educational efforts must work in tandem.
- Use qualified auditors and educators. Don’t assume that great coders will also be great auditors or educators. It takes a special person to deliver education effectively and know when someone is absorbing the information.
Coding audits and education improve coding performance, help ensure new ICD-10 coders hit the mark, identify opportunities to achieve coding compliance, maximize healthcare reimbursement, and fuel long-term ICD-10 education programs. Redesigning the audit process to address new ICD-10 challenges will help organizations meet their coding goals.
Source: Maximizing resources for ICD-10 coding audits. HIM Briefings, Volume 32 Issue No. 8, pp. 6-7.