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Be Prepared for Coding Changes

By Mary Beth Haugen, RHIA, MS, CHRI

The best defense against problems resulting from code changes is preparation. Follow these steps to ensure that your coding team members are educated about the latest guidelines and understand code changes.

Invest in Your Coders’ Education
We know it is coming! But are we prepared? Code updates! Do you have a plan? Is the education being provided effectively and timely? Investing in the right education at the right time will set your team up for success.

Mid-September is the ideal time to begin preparing your team for ICD-10-CM and ICD-10-PCS updates, giving them enough time to absorb the changes without forgetting the information. Typically for CPT updates, provide education in early December to avoid training over the holidays and year-end processes. Due to the 2023 E/M code changes, provider and coder education may be necessary as early as October or November.

Providing quality education and appropriate resources allows coders to understand the changes and apply the new or revised codes appropriately. There are many affordable educational offerings presented in different modalities, such as on-demand webinars or customized training. When considering the best delivery method for your team, think about whether it is best to view a webinar as a group or individually. Regardless of how your team views the content, facilitate group discussion, allowing for a more collaborative and meaningful learning experience.

Utilize the ICD-10-CM and ICD-10-PCS guideline documents from CMS’s website to create a comparison document to last year’s guidelines. This simple tool allows your team to quickly identify the changes for the upcoming year. Reviewing coding guidelines can be mundane, but it’s a critical task for every coder and should be included in your compliance plan. Even the most experienced coders will benefit from an annual guideline review, but combining it with a review of the updated guidelines will make it more palatable.

Encoders Are Not Enough
Quite often, coders are lulled into a false sense of comfort with the code changes, knowing that the encoder will be updated with the new code sets. Do not fall into the trap of “the encoder will take me there.” Make sure coders are aware not only of new codes but also of how the application of those codes can affect reimbursement. Each year, CMS releases more and more new technology codes, and many of those are given New Technology Add-on Payment status. This results in additional reimbursement to the facility to assist with the high cost of the technology. The encoder is only as knowledgeable as its user. Coders must know about new technologies that influence payment and ensure they are looking for those procedures and services in the medical record documentation.

Explore Potential Impacts
The impacts of not implementing code updates timely and accurately are many. Payers may deny the entire claim, causing rework as well as delayed reimbursement. Patient data may be misrepresented or inaccurate. These data are then shared with downstream applications, databases, and registries, causing delays and rework for many departments.

Use reports to identify unspecified ICD-10-CM codes and work collaboratively with clinical documentation improvement and providers to obtain specific documentation. While CMS has yet to finalize a policy that would remove unspecified codes from the complication or comorbidity lists under the inpatient prospective payment system, a new Medicare Code Editor edit became effective April 1, 2022. This edit is flagging unspecified codes to assist CMS in determining how unspecified codes will affect Medicare severity diagnosis-related groups in the future. Work proactively to improve documentation specificity to lessen the impact of future decisions.

Ensure Accuracy
Audits do not have to be punitive and are a helpful tool to ensure the new codes are being applied accurately. This is an excellent metric to determine if the fiscal year changes are being properly assigned. Audits should be performed using internal and external auditors. When choosing an external audit partner, ensure that they will incorporate education into the audit findings. Audit results should be presented in an environment with open dialogue, allowing your organization to discuss audit variances as well as providing a period for rebuttals and additional discussion. Remember that the most important part of the audit process is to educate coders and prevent future coding errors.

Depending on the impact of the changes to payment or compliance for your organization, a prebill audit may be necessary.

A retrospective audit should be conducted after October 1st. Depending on the volume of cases for a particular code change, the amount of time needed to perform an audit may be longer than others. For example, for FY 2023, dementia codes have been expanded to include specific codes for behavioral disturbances, a change that could affect a large number of cases in a short period of time. On the other hand, code changes for different types of aortic dissection may yield a smaller sample of cases, thus requiring a longer timeframe to collect more meaningful data.

After conducting audits and identifying areas of opportunity for your coders, provide education based on the specificity of these findings. Give your team time to complete the education and apply this knowledge before conducting an additional audit.

Remain Proactive
It’s best to remain proactive and conduct audits throughout the year. This will help identify opportunities in provider documentation, discover incorrect or unspecified codes, identify under- or overcoding, and prevent any potential compliance headaches that may be caused by inaccurate coding. The frequency of audits will depend on your audit findings and scores, but a routine internal or external monthly or quarterly audit with education will result in greater consistency, coder accuracy, and compliance.

Coders need timely and quality education to ensure competency and confidence in their expertise. This can be done internally or externally through audits, discussion of Coding Clinic releases, review of quarterly updates to payment systems, and formal education. Investing in your coders’ education will set your team up for success!

— Mary Beth Haugen, founder and CEO of Haugen Consulting Group and Haugen Academy, has more than 30 years of experience in the health care industry. Prior to launching Haugen Consulting Group, she held leadership roles in information services and HIM in a variety of health care settings. A passionate supporter of the HIM profession, Haugen has been a board member for AHIMA, AHIMA Foundation and the Council for Education and Excellence, AHIMA Leadership Advisory Panel, AHIMA’s Academic Task Force, and several offices for the Colorado Health Information Management Association (CHIMA). She’s been a member of AHIMA’s EHR Practice Council and also serves on the University of Cincinnati HIM Program Advisory Board. Haugen was the proud recipient AHIMA Triumph Award for Leadership and CHIMA Distinguished Member Award. She’s a nationally known speaker and author on topics such as ICD-10, information governance, the legal health record, integration of health care technology, HIM, and leadership. Haugen Consulting Group is the proud recipient of the CHIMA President’s Award and Colorado Company to Watch.