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January/February 2020

Ahead of the Curve
By Selena Chavis
For The Record
Vol. 32 No. 1 P. 14

To improve documentation, industry professionals embrace a more proactive, collaborative approach to concurrent coding.

Health care’s movement to concurrent documentation practices has been in play for a number of years as organizations ramp up clinical documentation improvement (CDI) practices. As the complexity of health care continues its upward trajectory, industry professionals believe that HIM must respond in kind by building on these models through innovative approaches that improve the patient story as well as timely reimbursement.

In recent years, the practice of concurrent and service line-focused coding has gathered momentum, according to Joni Dion, an associate director at Berkeley Research Group. “The coder begins the record review shortly after admission and follows the record through the final coding,” she explains, noting that missing documentation and clarification can be addressed while the patient is still being treated and coding accuracy, as well as revenue cycle, often improves. “Another concept to consider is pairing coders and clinical documentation specialists (CDS) to work in tandem. The coders and the CDS each have a unique skill and knowledge base and partnering can strengthen the review process.”

Diana Ortiz, JD, RN, CDIP, CCDS, CCDS-O, a CDI marketing manager with 3M, suggests that the industry is increasingly embracing these models—with some facilities implementing them across their entire organization while others focus on specific service lines.

“I would say more and more organizations are trying it and getting involved and saying, ‘Hey, if we are not going to do it systemwide, it would at least make sense to focus on areas where we’re really struggling and holding up accounts on the back end, or where we’re really struggling in quality,’” Ortiz says. “Because the CDI reviewer is not having to find the codes, they have more time and are able to get back into the chart every day. So, if there’s a real need around quality—for them to be looking more clinically at what’s going on with the patient—it’s a great opportunity for CDI to really get in there every day and make sure that everything is accurate.”

Five years ago, Atrium Health, (formerly Carolinas HealthCare System), a network of more than 40 hospitals across North Carolina and South Carolina, instituted this more proactive, collaborative approach to coding as part of a service line documentation excellence program. The initiative, backed by 3M technology, has grown into a broader effort to address whole record integrity, according to Heather Joyner, corporate director of documentation excellence in HIM for Atrium Health.

“It’s worked so well. The coders finally felt like they were part of the clinical team,” she notes, pointing out that the CDI folks are now able to work to their skill set since they no longer have to code the terms. “The coder starts coding the case the morning after admission, getting the working DRGs [diagnosis-related groups], getting the codes, and then, between the CDI professional and the coder, they would work together sharing their skill sets.”

The Need for More Proactive Coding Practices
The integrity of the health record speaks volumes. It represents the condition of the patient, services provided, and the continuity of care trail, Dion says, emphasizing that “the health record is the foundation for reporting in the public domain, hospital and provider profiling, and reimbursement.”

ICD-10 codes form the basis of most of these data, she adds, pointing out that traditionally, these codes are assigned by HIM professionals during chart reviews that occur after a patient is discharged. “Depending on the length of stay and complexity of care, this process can be time consuming,” Dion says, explaining that provider queries often accompany the process, resulting in further delays to final coding.

In the case of Atrium Health, Joyner says the organization identified the need for concurrent coding processes during an effort to better identify patient safety indicators (PSIs) while a patient was in-house. “We realized that the capturing of PSI was done retrospectively, after the fact. Then we realized that not only was coding looking at it, but quality was looking at it, and all these departments were looking at these PSI,” she notes. “We were all looking at them way too late and at different times, and it was redundant.”

In addition, Joyner says that Atrium wanted to improve the knee-jerk reaction that often accompanied coding mishaps. HIM would get blamed for coding inaccuracies that occurred after a patient was discharged when, in reality, the culprit was poor documentation practices.

Ortiz explains that traditional approaches to concurrent documentation entail a workflow in which CDI professionals begin chart reviews about 24 hours after admission, when there is enough good content to start identifying query opportunities. CDI would go back into the chart as frequently as possible during a patient stay to review documentation. Upon a patient’s discharge, coders would pick up the chart and start the process all over again.

“Over time, it’s just caused quite a bit of friction between the two roles, because you have a case where you’re trying to get [coding] out the door from a billing standpoint,” Ortiz says. “And now you’re having conversations about why CDI thinks this code is appropriate and why coding thinks a different code is appropriate. So, there’s this big dialogue that has been occurring after the fact, which is holding up things like their DNFB [discharged not final billed].”

As a result, Ortiz says many organizations are asking, “Why don’t we get coding and CDI talking sooner?” so that questions are answered in real time. A more collaborative approach would seemingly help improve documentation and minimize final coding delays.

Getting Coders in the Chart Earlier
Atrium Health’s first foray into more proactive coding workflows revolved around PSI identification on one of the organization’s general surgery units. Joyner notes that the initiative brought together coding, CDI professionals, and medical staff quality teams—those responsible for recording the PSIs.

Once a PSI was identified across a technology-enabled dashboard, the team would collaborate to determine whether an occurrence was truly a PSI or whether physician documentation needed enriching. “We had immediate intervention to make sure the documentation was accurate. If it really was a PSI, great, we would code it. If it wasn’t, then we could work with a doctor at that time,” Joyner explains.

Atrium later expanded this effort to other service lines, creating workflows in which coders begin accessing patient records the morning after admission. In addition, coders and CDI professionals communicate and collaborate throughout a patient’s stay. Joyner notes that teams use the DRG information coded in the patient chart during morning interdisciplinary rounds to consult with physicians. For example, if a patient stay has reached three days and the length of stay for a coded DRG is 3.2 days, CDI can consult with physicians to ensure proper documentation exists to support an additional inpatient day.

One area that has benefitted from the proactive coding workflow is cardiology, Joyner says, pointing to an effort to improve documentation related to 30-day mortality rates for acute myocardial infarction (AMI). The Atrium Health cardiac coding team comprises seven corporate coders who work remotely with facility-based CDI professionals. After reviewing historical data related to AMI mortality, Atrium deployed the new concurrent coding workflow to those facilities where the rates were highest.

Over the course of the first year, Joyner recalls that relationships and collaboration greatly improved across the multidisciplinary team. “We reached a place where physicians wanted to know who was coding their cases. It was a matter of relationship and trust, and they learned a lot from the process around documentation,” she notes. “They realized at that time that they had an opportunity to really improve documentation.”

Today, the cardiologists know that there is a set group of coders who work on the bulk of their cases. Notably, Joyner says that Atrium Health has gone from being in the “middle of the pack” in terms of AMI mortality rates to a high performer.

According to Ortiz, concurrent models introduce coders to several significant changes to how they’re used to doing things, most notably their ability to track their work. “Coders are very used to having the end of the story, unless they are waiting on a discharge summary or some sort of a pathology report,” she points out. “By the time they dive into the chart, historically, they got everything sorted, completed, right? So, getting them to understand that they need to almost mark where they left off from day to day and not have to start all over again, that’s where you gain the efficiency.”

Ortiz adds that the reengineered process also introduces a new element of empathy within the coding team because they understand more about the patient story and journey. “It’s brought about the realization that ‘I don’t have the whole story’ because it’s an evolving story,” she says.

The coders and CDI team at Atrium Health appreciate the opportunity to collaborate and use their skill sets to drive process improvement. Joyner says CDI professionals enjoy being freed from coding tasks to focus more on clinical validation and denials, while coders feel like they’re a more inclusive part of the clinical team.

“The coders that code concurrently say to me, ‘Oh, please don’t ever make me go back to doing retrospective coding,’” Joyner says, adding that coders enjoy the opportunity to look at the chart more than once. “We really feel like they’re part of the process around whole record integrity and documentation excellence. Once the patient leaves the house, the codes follow that patient wherever they go, and we want to make sure those are the right codes.”

The question for many HIM departments, Ortiz says, is how frequently should coders access and review charts. “I think that is definitely an organizational decision, as well as one where coders can provide key insights,” she says. “That’s what we’ve encountered with a lot of organizations because coders really have a voice into how well this plays out in terms of efficiency and success.”

For example, with some orthopedic patients, coders may determine that it is not necessary to come back into the chart until day two or three, whereas some postsurgical cases require daily review.

Prioritizing Change Management
Because each organization is unique, Dion says programs need to be developed and customized to best serve the specific needs of that particular facility. “Things to consider in the planning stage would be length of stay, staffing, and complexity of services,” she says. “Evaluate current challenges and look for proactive solutions.”

Change management is an all-important part of the success equation, Ortiz says. Many HIM departments have attempted concurrent coding and found it difficult to overcome hurdles. She cautions that although the new workflow design may receive pushback, technology can be a difference maker.

“I think some of the reasons why it works now is having the EMR in place that enables people to be in the chart remotely. We’re not waiting for paper records on a unit,” Ortiz points out, adding that organizations may have to convince some coders to give it another try. “You have to get their buy-in from the beginning. You have to make sure that they understand their new lane from the beginning—that CDI is no longer going to be assigning the working code. There has to be a lot of transparency and communication, which is different.”

Joyner suggests that the new workflow would not have been possible at Atrium Health without the right technological foundation, especially with coders working remotely. Collaboration is made possible through technology-enabled communication and the efficiencies of accessing patient charts in real time.

Forward-Looking Coding Practices
Joyner believes that the modern-day pressures related to value-based care and quality outcomes will necessitate that coders become more specialized within concurrent coding workflows, especially at large academic medical centers.

“I don’t think you can be a jack of all trades anymore,” she says, adding that some coders fear they’ll lose skill sets should they take a narrowed approach. “While a coder may only work on cardiology, they are now very deep and broad and wide cardiology coders. They understand the terms, what the doctor is writing or missing. That’s an awareness that a general coder would not have.”

— Selena Chavis is a Florida-based freelance journalist whose writing appears regularly in various trade and consumer publications, covering everything from corporate and managerial topics to health care and travel.