Best practices will rest on improving coders’ clinical practices knowledge
Use time, resources a little differently
For HIM departments to successfully navigate the new Medicare and health care territory of the 21st century, it’s important that directors look at managing time, resources, and intellectual capital a little differently than they have in the past. This can be done by establishing best practices for data management and coding quality.
"Coders need to become a lot more familiar with clinical practices," says Nancy Hirschl, CCS, vice president of revenue management services for Integrated Revenue Management of Carlsbad, CA.
"Twenty-five years ago, I was basically self-taught as a coder, and I knew that the whole classification system was a puzzle, and that’s what appealed to me about it," Hirschl says.
Now the medical field views coders differently. They need education and training, and even the term "coder" itself is outdated, Hirschl notes.
"Coders are people who put numbers on abstracts by looking in a computer program or book and putting a number on it," Hirschl says. "But we’ve done ourselves a significant injustice and disservice as DRGs evolve, because we’re really clinical data analysts — not coders."
As such, coders need to act like clinical data specialists, and this can be accomplished if an HIM department follows best practices in managing data and training staff, she adds.
Hirschl offers these suggestions for establishing best practices in data management and coding quality:
• Organize charts more efficiently.
Rather than giving each coder a stack of randomly assembled charts to code, an HIM department could take a little extra time to have the charts sorted according to body specialty, Hirschl suggests.
This is a method Hirschl first developed when she was a coder and now recommends to others.
"Say I have 50 charts, and I want to produce and do it right, so I’ll put all of my cardiac cath charts together, then all urologies, and then bronchiole biopsies," Hirschl says. "I take five minutes to look through each chart and then group them according to disease or condition, medical specialty, or body system."
In Hirschl’s experience, this was a very efficient process to follow, and she found that it worked with other coders as well, when she implemented the process as a coding manager.
"This is the beginning of what I believe we should implement as a best practice," Hirschl says.
This type of system two important things. First, it helps coders become more familiar with clinical practices because they are working on one disease or body specialty at a time, and the unbroken repetition reinforces their learning process. Second, this method allows coders to become more familiar with the physicians who are responsible for most of the documentation and charts in a particular area, Hirschl says.
"You’re increasing your speed because you are becoming more familiar with each case type and the whole function," she adds. "When coders work on charts by order of body part, they learn how to ask a question or query, and they become familiar with documentation and familiar with the clinical disease processes."
For example, after a coder has worked on five cardiac cases, he or she will begin to notice the same lab results, same tests, and same terminology, which improves the coder’s medical knowledge.
"This applies to coding outpatients as well as inpatients," Hirschl says. "I group all of my knees, colonoscopies, orthopedics, digestive, etc., together."
In Hirschl’s experience, coders love this system once they’ve learned it. "It increases their productivity, and the five minutes it takes to sort cases is not intrusive," she says.
• Improve workflow process.
An HIM director needs to identify practices that affect coding, such as whether the coding is from assembled or analyzed records and when it becomes time for a coding process to occur, Hirschl says.
"The department has to improve the workflow process around coding," Hirschl says.
For example, when records are retrieved or brought down for each discharge, they need to be placed in order and assembled in a consistent order of data information for each chart before they are given to the coders, Hirschl says.
"Coders generally look at a record like a book, starting with chapter one and following through to the end of the book," Hirschl says. "So it’s difficult for them to extract information when what is on page 10 should be on page 100."
• Encourage better physician documentation.
One best practices strategy to improve physician documentation is to have a physician liaison who understands coding and who can be used as a conduit to deal with the medical staff around documentation issues, Hirschl suggests.
"In addition, there needs to be a process where nurses or HIM coders work with physicians while patients still are in the hospital," Hirschl adds. "They can ask physicians questions about the lack of documentation or misunderstandings related to documentation."
• Focus on revenue cycle management.
Hospitals need to better manage their accounts receivable. This requires that coding managers and even coders understand the final discharge bill or chart from the hospital computer system, Hirschl says.
"We need to identify high-dollar cases and designate some kind of work processing where those charges might get coded first," Hirschl says. "We also should understand the difference between uncoded’ and unbilled.’"
Some charts are uncoded because the chart never got to the HIM department or because the coders cannot code it until they receive the dictation or transcription of significant reports, Hirschl says.
"And sometimes we can’t code because we have to ask the doctor a question," she adds.
Likewise, there often are cases where coders will apply a code, but the case is not billed. An unbilled record could be one that is sitting in a holding file because the payer requires an adjustment, Hirschl explains.
"A whole series of things might have been coded but still aren’t billed, and until it’s billed, it’s considered as an outstanding accounts receivable," Hirschl says. "So as a coding manager of best practices, I would want to find out the difference between uncoded records and unbilled ones."
An HIM department should know how to use the data and reports generated from the hospital’s HIM system and how to identify those cases that are not yet billed and/or coded, Hirschl suggests.
"Go find them and find out why they haven’t been coded or billed, and then correct them and get them coded," Hirschl says. "Find out why a case hasn’t been billed when, in fact, we coded it, and find out what we have to do to facilitate the bill."
While HIM managers might protest that this is the job of the business office and that their department has enough to do, there is a good reason for taking on this extra responsibility, Hirschl says.
"It’s a function that a sophisticated and mature coder would want to get involved with because, idealistically, it is what management looks at and thinks is best for the organization," Hirschl says.
Also, due to time constraints, it’s common to require cases to be charted and billed within three days of discharge, even though there often isn’t adequate information at that time, Hirschl says.
"I don’t agree that coding a chart that’s not ready is a good thing, but that’s what accounts receivable is all about," Hirschl says. "The billing department will drop bills quickly so there are no outstanding payments, but that’s not the best way to manage coding, so there’s a disjoint between cash flow and coding quality."
If at all possible, coders should make sure there’s enough time to obtain all of the necessary documentation before completing a chart’s coding and letting it be sent out for billing, Hirschl adds. "Also, help the billing department get rid of the backlog, because that helps both departments."