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The Importance of Keeping Your Coding & CAC Applications Up to Date

By Darice Grzybowski, MA, RHIA, FAHIMA

Clinical coding technology applications continue to advance at rapid rates within health care systems, hospitals, physician practices, and ambulatory and other outpatient environments. While all the platforms that house coding, demographic, and financial data are not necessarily fully interoperable, there is still significant use and sharing of reporting data. Of particular importance to mention is ICD 10-CM, ICD 10-PCS, and CPT/HCPCS code sets due to their significant role of codes in epidemiological historical research, insurance reimbursement, patient outcome statistics, and overall morbidity and mortality measurement processes for improving quality throughout the care provider environment.

Computer-assisted coding (CAC) encompasses tools to help professional coding staff assign these codes and includes software such as encoders, groupers, and national language processing applications. A number of software tools for CAC have become interwoven into the workflow of coding and continue to become more advanced and now integrate clinical documentation improvement and deficiency (incomplete record processing) functionality.

Challenges
One of the major challenges encountered by the HIM department, the IT department, and the full revenue cycle team is how to synchronize these automated systems between each other as well as keep the databases that support these technologies current. CPT codes are updated annually (January 1st), HCPCS Level II codes are updated quarterly, and ICD-10-CM/PCS are updated each April 1st and October 1st. The varying dates and the irregular update delivery schedule from various vendors can play havoc with coding workflow.

The discharged patient records must correlate to the rule set of the applications based on the effective date of the code changes. Since diagnosis-related groups (and other prospective payment grouping systems) can change in tandem with the specific code changes, grouper updates must coincide and be implemented simultaneously even if the software is sourced from different vendors. Complicating this further is that applications may be managed by one department in a hospital and other applications by a different department. The scheduled calendar date for the code updates might occur on a weekend or a holiday in which staff support may not be available to perform the update. In some cases, vendors may deliver an update late or issue multiple errata/addendums, causing disruptions in a smooth update of an application.

What Happens When the Update Isn’t Timely?
Anyone who has lived through a delayed update can tell you it is not fun. Even worse is what can occur when databases are not synchronized. Delayed code updates can cause a major backlog in processing as (paper or digital) records must be “held” so that they are not processed with an outdated set of rules that can result in wrong code assignments. The cost of “reprocessing” a record if it contains an error can be prohibitively expensive. Attempting to explain the wrong codes once a payment is denied can require a lengthy and expensive appeal process. If errors are identified during an audit, lost revenue or prorated financial penalties may result.

Errors in one system can easily proliferate into another system. Reports may be distributed based on faulty data and decisions made—whether in physician credentialing, budgeting, or clinical treatment protocols—can turn problematic when erroneous data are proliferated and replicated simply because the code sets are out of date. In the case of CAC applications based on natural language processing and other machine learning, erroneous identification of the codes could be inaccurate, leading to compliance and reimbursement issues.

Clinical registries that collect outcome data could be passed onto state registries and associations and impact future treatment protocol development. As data are being used more in real time, and big data can be impacted by trended data, often based on codes, ensuring all CAC applications stay current and accurate will become increasingly important.

Tips for Managing Upkeep of Your Code Sets
1) Since a facility may be dealing with varying leaders, departments, vendors, and software applications, it is important that the update process become a systemwide maintenance policy and procedure that can be followed to ensure smooth transitions.

2) A control chart can be developed that includes the following: each system “owner,” the name of the software application which contains any codes, the vendor contact information, the date of the expected delivery of the update, the individual responsible for the update, and then the actual date the update is completed. A single individual should bear responsibility to ensure updates and the surrounding communication process occurs smoothly throughout the organization.

3) Notification of the anticipated update and any resultant “downtime” or summary of changes of the code sets should be sent to all executive or operational staff so that they are aware of any impact the changes may have on reporting data, decision making, or procedural training for staff that may need to take place.

— Darice Grzybowski, MA, RHIA, FAHIMA, is the CEO/founder of H.I.Mentors, LLC and has been an HIM administrator, consultant, educator, author, and international speaker for the past 35-plus years.