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March 31, 2008

Paired for Success
By Elizabeth S. Roop
For The Record
Vol. 20 No.7 P. 10

Documentation improvements and inpatient prospective payment system changes are driving interest in concurrent coding.

When the Centers for Medicare & Medicaid Services (CMS) announced plans for changes to the Medicare inpatient prospective payment system (IPPS) by replacing diagnosis-related groups (DRGs) with severity-adjusted reimbursement, hospitals nationwide began taking a closer look at their coding processes to improve documentation and ensure that all codes affecting reimbursements are being captured and billed.

The answer for many facilities has been to introduce—or reintroduce—concurrent coding programs where coders are on patient floors reviewing charts for documentation opportunities and querying physicians in real time.

Specificity Required
In October 2007, to improve the accuracy of payment rates for inpatient stays, the CMS replaced DRGs with Medicare severity diagnosis-related groups (MS-DRGs) and created a second level of complication and comorbidity (CC) codes called major CCs (MCCs). At the same time, new rules took effect requiring hospitals to report a present on admission (POA) code for all principal, secondary, and some E- and V-code diagnoses.

“All of these things happened at the same time and became a huge impetus for everyone to focus on clinical documentation improvement,” says Debi Primeau, MA, RHIA, the vice president of professional services at Precyse Solutions. As a result, coding and documentation must “better reflect the actual patient care and better reflect the severity of that patient’s illness in the medical record before discharge.”

For hospitals, the changes translate into a need for more complete, specific coding and sequencing them into the allowed diagnosis fields on the UB-04 to maintain revenues and quality reporting under the MS-DRG system. That, in turn, requires more comprehensive and specific documentation to support additional coding.

But it is not just the immediate impact the IPPS changes have on revenues that is driving hospitals to improve coding and documentation. It is also the long-term effect documentation can have on quality reporting for both hospitals and physicians, particularly with the advancement of pay-for-performance systems.

“Bottom line is we want documentation to improve so that we can assign the codes not only for reimbursement, MCC, and CC capture but for data quality to make sure morbidity and mortality of the patient is represented by their code, which gets reported through all the various quality initiatives out there,” says Carol Spencer, RHIA, manager of professional practice resources for the AHIMA.

Making It Work
CHRISTUS Schumpert St. Mary Place, a 601-bed acute tertiary care facility in Shreveport, La., and its sister facility, 160-bed CHRISTUS Schumpert Highland, each employ two concurrent coders who head for the floor to obtain working DRGs whenever a Medicare patient is admitted. The coders follow the patient from admission to discharge, attending case conferences and working with the clinical team to ensure that documentation is as specific as possible.

When queries are necessary, concurrent coders can often pull the physician aside and get the information. They can also show exactly why they are making the query in the first place. “When the coder finalizes that chart at discharge, it is a whole different creature than it would be if not for concurrent coding,” says HIM Manager Timothy R. Rogers, MBA, RHIA.

The program was established after a careful analysis to determine whether and why concurrent coding was needed and how it would benefit the facilities. Training sessions were held to educate case management, physicians, and nurses about how the coding process is impacted by documentation levels and the kinds of queries the coding system kicks back for response.

That level of communication between concurrent coders and the clinical staff has helped St. Mary Place and Highland secure physician buy-in and realize early benefits from the program that go beyond the financial gains from an improved case mix index.

“It really helps you better identify the patient services [provided] and helps drill down to get the MCCs and CCs. With POAs, physicians really have to dot the i’s and cross the t’s. If you can show them the end results of implementing concurrent coding, show them the data, and let them make up their own mind, there is really only one conclusion they can come to,” says Rogers, who adds that the program’s chief benefit has been the partnership that has developed between the medical staff and health information.

“Through concurrent coding, we [HIM] have become an integral part of the team on the floors. We don’t do the clinical side, but we assist with documentation on the clinical side. We’re on their side, and they understand that everything we ask and try to get them to do is for their benefit,” he says.

Fairfield Medical Center, a 222-bed not-for-profit acute care facility in Lancaster, Ohio, has experienced similar results from its concurrent coding program. Launched in 2003, the program involves getting coders on the floor to begin concurrent coding by the third, or preferably second, day after admission.

On the floor, coders read through all admitting documentation. They post queries to the chart while on the floor, getting physicians to respond and document along the way. Then, upon discharge, the same concurrent coder final codes the chart.

Wireless issues prevent coders from bringing laptops onto the floors. Instead, they utilize a worksheet to capture the notes needed while reviewing the chart and then enter the codes into the system when they return to the coding department. “It’s a little bit manual, but the coders felt it was faster than carrying around a laptop that would only work half the time,” says Alesha Riffle, RHIT, of Fairfield’s coding compliance.

As is often the case, physician buy-in was the medical center’s biggest challenge. Backers of the program solicited support from the physician leadership and tapped into a few unofficial liaisons among physicians who have really taken to the program to overcome that obstacle. They also rely on case management, which has a close working relationship with the medical staff, to intervene on their behalf when physicians aren’t responding.

Physicians “have definitely accepted it more now than they did a couple of years ago when we started. We’ve helped them along the way to understand why it’s important. We’ve really tried to use the spin of how it affects them because it does in terms of quality ratings,” says Riffle, adding that the work required to overcome the challenges is worth it in the long run.

“Our documentation is more accurate, which allows us to give a more accurate picture of the patient’s illness and helps with quality ratings in terms of severity of illness and risk of mortality scores. It leads to the most accurate reimbursement. We don’t like to say the highest reimbursement but the most accurate reimbursement,” she says.

Learning From Past Mistakes
There are no guarantees that concurrent coding will succeed in every facility every time. Sometimes it is necessary to admit failure, regroup, examine what worked and what didn’t, and try again.

That is what Fairview Red Wing Medical Center, a 50-bed facility in Minnesota, did when it relaunched its concurrent coding program in late 2007. The first attempt four years earlier didn’t last, primarily due to a lack of buy-in from both the clinical and coding staffs. “It was interesting because we didn’t have a whole lot of excitement for volunteering [among coders]. They were supportive but not jumping in,” says Shari Christianson, RHIT, Fairview’s coding supervisor.

However, this time around, the program has the full support not only of the coders but also of the hospitalists, nurses, and the director of inpatient services. That support was critical to success because the current program required providing coders with office space on the patient floors where they could set up a computer to do their work and still be in the mix.

Coders spend one week on a rotating three-week schedule doing concurrent coding, during which they work on the floors and interact directly with the clinical staff, including attending morning rounds reports.

“They are accepted as part of that group in the morning. They are expected to be there,” says Christianson. “Some hospitalists actually give the concurrent coder time to ask questions. That inclusion says a lot about the success of our program.”

During their week in the medical records department, coders help maintain continuity by completing any concurrent coding records they couldn’t finalize while on the floor.

“One thing about our program that was a huge benefit was that it was implemented about the same time that MS-DRGs came out, so we promoted [concurrent coding] and educated the physicians on both topics at the same time,” says Christianson. “When they realized the huge changes in the DRG system and how it impacted reimbursement and documentation, that helped with their buy-in because what they did know about the previous DRG system no longer held true. They relied on us to be experts in that area.”

Northern Michigan Regional Hospital, a 243-bed regional referral center located in Petoskey, Mich., has also seen its second attempt at concurrent coding flourish. A consultant was hired to handle the initial evaluation and analysis necessary to sell the administration and physicians on the idea of reestablishing the program and then designing a program that teams coders with clinical partners who have a good relationship with the medical staff.

Clinical partners and coders were put through a training course on coding, diagnosis, and procedures that roll out to the DRGs. This set the stage for the concurrent coders to take over space on the patient floors where they could review records, start the coding process, and work with their clinical partner to get responses to any necessary queries.

“One of our challenges with this new model was relocating the coders to the nursing units,” says Kathy Beyer, Northern Michigan’s director of revenue cycle. “Building relationships between them and their clinical partners eased them into it.”

Beyer credits the success of the iteration of concurrent coding to several factors. First, a change in leadership brought in a chief financial officer who had seen the program succeed at another facility. Second, there was a renewed interest from physician leadership, who now devote a section of their newsletter to coding updates and tips. Third, a tool that tracks success on a monthly basis was implemented. To date, concurrent coding is credited with a gain in annual revenues of more than $800,000. The entire process is accelerated as well, with records coded within 24 hours of discharge.

“We’ve seen it in our quality data, as well through the documentation process,” says Beyer. “The fact that we’re querying physicians early on means we’re getting more of the comorbidities and complications documented in the medical record, so as they’re looking at their quality data … We’ve seen improvements. We can definitely demonstrate that the acuity of our patients is higher than our data was demonstrating prior to June 2005.”

The Best of Both Worlds
Whether the impetus is quality improvement or enhanced revenues under the new MS-DRG system, the concurrent programs at many facilities have demonstrated that merging the clinical and coding worlds can have the desired effect.

Primeau notes that programs such as Northern Michigan’s, which teams coders with clinical partners, may have the greatest chance for success because “you’re pulling the clinical knowledge of the case manager and adding the expertise of the coder into that equation, so you have the two of them translating the medical record documentation from the physician.”

In fact, merging the two worlds through programs such as concurrent coding is perhaps the most effective way to respond to quality-based initiatives, adds Spencer. “The biggest thing that came out of the whole POA process is that interdisciplinary, arms-linking approach to really improving patient care. Coding now becomes so critical to identifying opportunities to improve standards of care,” she says. “It ties the whole interdisciplinary clinical reimbursement coding team together because they work together to improve the quality of patient care.”

Elizabeth S. Roop is a Tampa, Fla.-based freelance writer specializing in healthcare and HIT.