DRG Coding Advisor: To improve quality data, HIM pros face challenges

Here are five of the most common problems

HIM professionals in acute care hospitals are key players in the collection and assessment of the data required under the Medicare Outpatient Prospective Payment System (OPPS).

While it’s their job to maintain quality data, there are certain challenges and requirements that must be kept in mind when undertaking the task of improving data quality under the OPPS, says Cheryl D’Amato, RHIT, CCS, director of HIM for HHS Inc. of Hamden, CT.

D’Amato suggests HIM professionals watch for these data quality challenges:

1. Invalid, missing, or incorrect reason for visit.

The determination of the medical necessity of many procedures performed depends on accurate coding of the reason for the visit. These diagnoses often are assigned by scheduling and registration staff not familiar with ICD-9-CM coding, D’Amato says.

"The staff in these scheduling and registration areas do not realize the potential impact of incorrect information on the data quality and reimbursement to their facility," she says.

"Consider assigning an HIM coder as a liaison to the scheduling and registration areas of the facility who can be called on for coding questions and who can provide continuing education on coding and regulation changes," D’Amato suggests.

Other strategies include using software and initiating operational changes to provide editing to determine medical necessity before the services are rendered.

2. Invalid, missing, or incorrect diagnoses and procedure codes.

Prior to the implementation of OPPS, outpatient coders typically were not credentialed and did not have any real knowledge of the ICD-9-CM and HCPCS classification systems, D’Amato notes.

HIM ambulatory surgery coders, especially in light of OPPS, should have an in-depth knowledge of ICD-9-CM diagnoses and HCPCS coding, D’Amato says.

Emergency departments (EDs) may have HIM coders assign diagnoses and most procedure codes, while nursing may assign evaluation and management codes.

Coding for procedures performed in ancillary departments is generally chargemaster-driven or is performed by inexperienced coders. Diagnosis coding for these services is generally performed by HIM coders with little or no documentation, D’Amato says.

"The challenge for diagnosis coding on these accounts is the lack of information with which to determine the medically necessary’ code assignment," D’Amato explains. "Often, charges are entered on these accounts by the ancillary department providing the service, with little collaboration with the diagnosis coding function."

So the solution is to document the entire coding function, including responsibility and necessary skills.

For example, consider requiring credentialed coders in the HIM department, D’Amato says.

"There is a critical shortage of credentialed coders," she says. "Because coding requires a variety of different skills, it is important to educate and cross-train other staff on those issues and coding requirements related to their specific department or service. Then consider assigning an HIM coding professional as a liaison to ancillary departments to answer questions and to evaluate requisition and charge forms."

Another strategy is to audit high-volume and high-cost services to evaluate coding and resulting reimbursement and to utilize the findings of these audits to educate coders and to revise policies.

3. Obsolete, inaccurate, or incomplete charge description master (CDM).

There are a number of data quality challenges related to the CDM.

The fact that two-thirds of all outpatient reimbursement is generated by the CDM must be taken very seriously, D’Amato says.

For instance, HCPCS codes are updated quarterly, but if these changes are not made in the CDM, it will become outdated. When this happens, facilities will miss new transitional pass-through payments or may be reimbursed incorrectly, D’Amato says.

"Each department has traditionally been responsible for updating their chargemaster, but staff are not often familiar with the HCPCS classification system," D’Amato says.

A solution would be to create a CDM team or department to be responsible for educating and assisting departments in the CDM evaluation and update process.

"Communicate regulatory and HCPCS code changes to all relevant departments," D’Amato advises. "Creating a structure that keeps everyone on top of the changes is critical to the process."

Also, HIM professionals should consider utilizing software to assist in the CDM process, and they might use credentialed HIM coders as a resource or as members of the team.

4. Inadequate or improper use of modifiers.

Two key areas where modifiers are missed are in the ED and in CDM assigned codes.

Modifier -25 is often missed in the ED when nursing assigns the evaluation and management code and the HIM coder assigns the diagnosis and procedure codes, D’Amato says.

"One solution for both of these issues is to allow the CDM codes to be available to the HIM coders so that they may add these modifiers when appropriate," she adds. "Missing modifier -25 on ED claims will have significant reimbursement implications."

For example, the medical services provided may not be reimbursed, so HIM staff should consider including modifiers in the CDM for some services.

5. Outpatient Code Edit (OCE) failures.

In addition to editing outpatient claims, the OCE dictates claim and line-item reimbursement.

The OCE includes a portion of the national Correct Coding Initiative edits as well as code validity edits, unit edits, and a number of other types of edits, D’Amato says.

Unfortunately, there are no complete quarterly revisions to the OCE published by the Centers for Medicare and Medicaid Services, she notes.

This is a problem, because program memorandums do not explain how the OCE works, and nowhere is there a complete code list for each edit.

Pass all claims through OCE software

"Nor is there documentation of all of the changes from one version to the next," D’Amato adds. "Therefore, it is important that facilities utilize OCE software during the coding process to identify edits before the claim is sent to billing, and it’s even more important that a batch process be in place so that all claims are passed through OCE edit software before the bill drops."

This will ensure that claims are not being submitted for payment inappropriately, D’Amato says.

OPPS poses other challenges, as well. For instance, providers will continue to struggle with ever-changing OPPS requirements, D’Amato says. But this will be less of a struggle if procedures are in place to deal with these changes. "Monitor the CMS OPPS web site, communicate changes to all relevant departments, evaluate how to deal with these changes, and continue to evaluate operations and make improvements," she recommends.

Also, it will be crucial to educate all departments about medical necessity, ICD-9-CM, and HCPCS coding, D’Amato says.

HIM professionals should keep in mind that implementation of the 2002 OPPS changes has been delayed.

"Documentation requirements and other OPPS issues will continue to be a challenge but are essential for assuring that there are no gaps in data quality that affect reimbursement," D’Amato says.