HTH Iowa Project Workshop: Monitoring Coding Productivity ... · Healthcare Coding and Consulting Services (HCCS) Angela Hartman, CCS, CPC Outpatient Coding Manager Healthcare Coding

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HTH Iowa Project Workshop:

Monitoring Coding Productivity; Coding Efficiency

Process Mapping

Melissa Edenburn, RHIA, CCS, MS

AHIMA Approved ICD-10-CM/PCS Trainer

Senior Inpatient Auditor and Trainer

Healthcare Coding and Consulting Services (HCCS)

Angela Hartman, CCS, CPC

Outpatient Coding Manager

Healthcare Coding and Consulting Services (HCCS)

© 2015 Healthcare Coding & Consulting Services© 2015 Healthcare Coding & Consulting Services© 2015 Healthcare Coding & Consulting Services

AGENDA

Progress to date FY 17-18

Defining Productivity and Best Practices

Identification of Areas of Opportunity

Policies and Procedures

Identifying and Measuring Areas of Risk

Audits and Monitoring

Defining Best Practices

Process Mapping and Tips to optimize coding efficiency

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© 2015 Healthcare Coding & Consulting Services3

Disclosures

The education offered by HCCS in this program is compensated by the Iowa Department of Public Health Small Hospital Improvement Program

(SHIP) under grant number 5887SH01.

HCCS does not have any proprietary interest in any product, instrument, device, or material discussed during this learning event. HCCS stands to benefit from the provision of services designed to address topics covered in this presentation.

MONITORING CODING PRODUCTIVITY; CODINGEFFICIENCY PROCESS MAPPING

© 2015 Healthcare Coding & Consulting Services


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• Steps

• Measures

• Analysis

• Tracking

Speed• Monitoring

• Benchmarking

• EducationQuality

• Standards

• Policies

Best

Practices

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Part 1:




Take the Test to determine area for opportunity

Do you have productivity expectations currently?

Have you seen a decrease in productivity after ICD-10

Go Live, of which has not increased to date?

How do your coders stack up against each other or standards

industry wide?

Do you have a trackable way to measure productivity, or a data based

process to ensure you are optimizing resources?


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Asking the Questions…

What are Coding Productivity Standards?

Do you need Productivity Standards?


MONITORING CODING PRODUCTIVITY; CODING EFFICIENCYPROCESS MAPPING

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Audience Poll Question and Discussion #1

Do you have established

Productivity Standards for

your Coding Staff?

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Step One:

Categorizing Coder Responsibilities



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Understanding the Process is Crucial

Understand the Process

Know the steps involved

Sources supplying the information

What problems are coders encountering during the process?

Have the coder record the time!

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Look for areas of Opportunity…..

What redundant steps were observed?

- Examples include adding CPT’s in the encoder and in

B/AR side via charge (duplication). Is it needed?

- Are coders adding items in the encoder and in the system

duplicating efforts?

Example: Abstracting REV codes, or date of procedures



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Coder’s don’t just code, they…..

Answer Questions from the Billing Office/ Patient Financial Services

Answer Calls/Questions from Physician Offices

Answer Questions from Case Management/UR

Querying Providers

Placing Deficiencies

Appealing Denials

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Coder’s don’t just code, they…..

Obtaining Information to support medical necessity

Assisting with RAC requests

Back up Scanning

Assign working DRG’s (Concurrent coding)

Assisting with Release of Information (possibly)

Performing Clinical Documentation Improvement Functions

Peer to Peer questions


Action Items

List: Start to Categorize Coder Job Functions

Coding Time

Working Denials (i.e. LCD/NCD), continue…

Involve the coders

Ask where they are spending their time daily

Ask estimates of time they believe they are spending time on daily

Compile into one working list


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Involvement of Coders Continued…

Why Coder involvement is key….

HIM responsibilities uncover diverse functions

Participant buy in by inclusion in the planning phase




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Step Two:

Collect and Analyze Data

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Do Systems (EHR) Impact

Coder Productivity?



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Does having no

encoder Impact Coder

Productivity?

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Additional Variables that Impact Productivity…

Type of Systems

Volume of Systems

Types of items abstracted

- Modifiers on hard applied items

- Hematocrit and Hemoglobin value codes

- Place of Occurrence Codes

Charge Entry

CPT’s on Inpatients or not


Defining “what” is involved

Is the coding only Diagnosis only?

Does the coding involve applying modifiers to soft and hard applied

codes?

- Defining what soft vs. hard applied is

Are E/M’s coded by coding?

Are Infusions and Injections coded?

What are your query rates?

Is there “auditing” of charges involved?

- Does this involve review, crediting, and/or working with the departments?


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Observation Phase

Track time for 2 weeks

- By coder

- By category of function

- By Time spent

- By volume of charges coded, by chart type

What is a time study, and when is it beneficial?

How are you measuring (IP) longer Length of Stay accounts (LOS)



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Question Everything for Opportunity

What functions can be streamlined?

What functions should coding not be involved in?

What is taking your coder away from coding?

What should be incorporated into their process that is not now?

Do you coders frequently run out of work?

What does not “add up” when reviewing the information

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Question Everything for Opportunity- Continued…

Ares that increase Productivity

Legibility and Consistency of Documentation

Availability of Chart Documentation

Encoder

EHR

Coder Education



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Ares that increase Productivity

Remote vs. Onsite Coders

Right task performed by the right person

Standard forms in use

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Ares that decrease Productivity

IT issues and connectivity

Technology – Example: Dual Monitors

Missing Documentation – Timing is everything

- Example: Coding Emergency Charts – Questions to ask

- Example: Coding Inpatient Charts – Consider Scanning timeframes

Lack of complete, concise, and strong documentation



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Ares that decrease Productivity

Validating ABN’s

Analyzing Chart Documentation while coding

Auditing Departmental Charges

Let’s Look at an Example Together…

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Auditing Departmental Charges

Coding Audits

Coding Reverses Charges

Coding Adds Charges

Coding Finalizes

Coding Audits

Coding Places on

Hold

Coding Notifies

Department for

Correction

Coding Finalizes

Code and Charge/Coding

Finalizes

Best Practice



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Areas that decrease Productivity

EHR – Chart Image Categorization

- All images placed into one running image (hundreds of pages)

vs. partitioned by image type

Example: Patient comes in and has an order for Lab services

System A: Images include one file of 89 pages of lab findings and on page 77

is the order

System B: The order is indexed under “order”, therefore the coder clicks on

one image to view

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Step Four:

Develop Standards, Policies and Procedures



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The Golden Question…

Is there a one size fits all productivity quota for coders by chart type?

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Case Study Example Productivity:

Hospital A

Inpatient: 24

SDS: 48

OBS: 24

Emergency Room: 120

Rational….



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Hospital B

Inpatient: 32

SDS: 56

OBS: 56

Emergency Room: 75

Rational….

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Hospital C

Inpatient: 5

SDS: 4

OBS: 2

Emergency Room: 32

What does this scenario tell you about possible areas of

opportunity?



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Sources for Productivity Benchmark Guides

AHIMA American Health Information Management Association (AHIMA)

http://campus.ahima.org/audio/fastfacts/FRB0602.pdf

AAPC (American Academy of Professional Coders) https://www.aapc.com/

http://campus.ahima.org/audio/fastfacts/FRB0602.pdf

https://www.aapc.com/

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Formula Examples

Completed work = Total work output – Defective work

Labor productivity = ______Completed work_________ Hours worked to produce

total work output

Source: Miller and Waterstraat, 2004



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Example- Inpatient Coding Productivity Calculation for one Month

Definitions to Apply

• Percentage of work completed by auditCompleted work percentage

• Work output multiplied by completed work percentage Completed work Output

• Completed work output divided by total hours worked Completed work per hours

worked

• Number of work units recorded by the employee for the process Work Output

• Number of hours the coder worked of productive time, This does not include lunches, meetings, or coder breaks

Total Work Hours

• This is the work output divided by total hours workedAverage work output per Hour

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Example Continued.. Inpatient Coding Productivity Calculation for one Month

Source: Health Information Technology: An Applied Approach

Coder Work Output (Coded records

Total Hours Worked

Average Work Output per Hour

Completed Work Percentage

Completed Work Output (records coded accurately)

Completed Work per hour worked

A 500 140 3.57 91% 455 3.25

B 475 140 3.39 96% 456 3.26

C 300 80 3.75 96% 240 3.00

D 375 80 4.69 64% 240 3.00

Department Average

3.69 3.13



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Example Capturing Data

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AHIMA Survey Standards

Emergency Department – 120 a day

Ancillary Department – 240 a day

Ambulatory Surgery – 240 a day

Inpatient – 24 a day



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Poll Question and Discussion #4

How do your Productivity Standards

compare to these previously published

by AHIMA?

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Differences Are Acceptable

Coding Responsibilities Vary

Degree of Automation/Systems

Documentation EHR

Type of Billing Requirements in compare to Acute PPS Facilities

Examples:

- CPT on Inpatients

- Coding the ED portion off a ED Admit as a discharge (Billing carve outs)



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Define Standards by Chart Type

Inpatient __ per hour/day

Same Day Surgical __per day/hour

Ancillary OP __ per day/hour

Observation __ per day/hour

Emergency Room __ per day/hour

Clinic __ per day/hour

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Step Five:

Develop Monitoring Processes

and

Assessing Actual Staffing Needs



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Monitoring Timeframes

Daily, weekly, or monthly

Look for Red Flags

Too Fast?

Too Slow?

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Staffing Levels - Now is the time to assess!

Staffing and Productivity

Why is this important?

How is this calculated?



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How Many Coders do you actually need?

Determine FTE’s

Step 1: Defining what is a FTE by identification of approved hours per pay period

Step 2: Calculate and identify non worked paid hours

Step 3: Know the average volume of patient encounters

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Formula to Calculate Staffing Levels for Coding

Example of Formula: Clinic Scenario

Number of FTE’s Needed= Patient Encounters Productivity

2.5 FTE’s = 250 Encounters100


Action Items


Collect Actionable Data weekly

Determine who is responsible for monitoring

Identification of Gaps

Assess Staffing Needs

Look for opportunities

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Sharing of Best Practices

Ideas to Pass Along



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Poll Question and Discussion #5

What do you think Coding

Accuracy Standards

Industry wide are typically

set at?



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Nationwide 2nd Annual

ICD-10 testing challenges

the “all is fine theory”

Coder Credentials

Published results from Central Learning “contest”

550 coders tested

99% were certified o 59% AHIMA Certified o 28% AAPC Certified

1% not certified

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Nationwide ICD-10 testing challenges


Experience Level of Participants

Inpatient Coders experience -14.3 years

Outpatient Coders experience- 9.9 years



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Scope of the Contest

1,636 medical record cases

Coders could “Choose” their area of Specialty for Test Purposes

All Questions/Answers were validated by industry certified experts

- Consultants

- Internal and External

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Inpatient 54%

SDS20%

ED26%

Chart Type Volumes

Inpatient

SDS

ED



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The results…….

Coders accuracy and proficiency in ICD-10 remains much lower than 95%

Sub-par findings with DRG Accuracy, significantly impacting revenue

Average inpatient coder accuracy: 61 percent

Average ambulatory surgery coder accuracy: 45 percent

Average emergency department coder accuracy: 36 percent

Study shows Increased Productivity and Grossly Sub Par Quality….

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Central Learning “Coding Test” Year Two results

Source: Journal of AHIMA 2017



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Productivity Findings….

Higher productivity decreased inpatient coding accuracy by -25.4

percent

Higher productivity decreased outpatient coding accuracy by -20.3

percent

http://journal.ahima.org/2017/10/06/2nd-annual-icd-10-coding-contest-results-sponsored/

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ICD-10 challenges

Coders have questions, it’s ok.

Do you have an onsite ICD-10 expert?

Even in 2018 everyone has interpretations without source backing

Lack of coder feedback and education on their work

Bad habits were formed early on

Lack of adequate documentation Defining Coding Challenges

Understanding the importance of Source Guidance



Keys to Success

Partnering up with the experts

Proof of Continuing Education Participation

Assess your weaknesses

Open Environment is a must

Knowing the sources

Buyer beware

Knowing your resources


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Coder Education

Know your sources!

Know your Code maintenance schedules

Provide education, don’t assume your coder is handling

Leveraging technology to provide cost-effective education,

especially those with limited time or resources



Best Practices

Monthly/ongoing training is imperative

Possible Areas to include: - Review of the OIG work Plan

- Current CPT Assistant reviews

- Current AHA Coding Clinic reviews

- Changes to the PPSs

- Annual CPT Changes (January)

- Annual ICD-10 Changes (October)

- Clinical Information related to coding (procedures, disease process etc.)

- Identifying your teams weaknesses, and providing group remedial


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Take the Test to determine your risk

Do you offer mandatory education to your coders

currently?

Are your coders credentialed?

Do you validate your coders recertification and mandated CEU’s?

Do you have coders who code multiple specialties (i.e. inpatient/outpatient)?

Do you have access to and review the most current education, such as

Coding Clinics quarterly, CPT assistants?




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Sharing of Best Practices

Ideas to Pass Along

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Do you have Coding Policies and Procedures in HIM

and available to your Coding staff?

Have your Policies and Procedures been reviewed for accuracy within the

last 12 months?

Do you have a expected coding accuracy rate documented within your

policy and procedures?

Do you have a expected coding productivity rate documented within your

policy and procedures?



Example Policies and Procedures:

Audit and Monitoring System

- Audit/Monitoring Schedule

- Concurrent Audit

- Targeted Audits

Quality Management and Assurance Reporting

Remote Coding

Job Descriptions (Coder I, II, III, etc.)

Performance Management (Performance Reviews)


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Example Policies and Procedures Continued:

Rebills Process (APC/DRG Changes)

Ambiguous or deficient documentation

Explanation of Source Guidance (Official)

Process when no Source guidance is available

Coding TAT expectations



Code of Conduct

Every HIM should develop a code of conduct

AHIMA’s Standards of Ethical Coding

AAPC’s Standards of Ethical Coding

http://bok.ahima.org/doc?oid=106344#.V3-yeRYebIU

https://www.aapc.com/aboutus/code-of-ethics.aspx


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Do you concurrent audit certain DRG’s,

pre-bill?

Do you target certain DRG’s retrospectively?

Are you familiar with target areas from OIG, CMS, RAC and

incorporate them into your internal monitoring?



Current CMS Audit Environment

• Recovery Auditor Program (RAs)

• Medicare Administrative Contractors (MACs)

• Medicaid RACs

• Quality Improvement Organizations (QIO)

• Medicaid Integrity Contractors (MICs)

• Zone Program Integrity Contractors (ZPICs)

• State Medicaid Fraud Control Units (MFCUs)

• Comprehensive Error Rate Testing (CERT)

• Payment Error Rate Measurement (PERM)


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Action Items

Become Familiar with the “Hot Topics”

• Auditing and monitoring Systems in place

• Effective communication mechanisms in place

• Take a good look at denials



Action Items

Writing Policies and Procedures

Ensure Education needs are met

Importance of credentialed Coders

Ensure the right tools are available

Review where your facility's area of risk is, take action!


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Action Items

Validate if your Productivity Standards are

Correctly set, and look for areas of opportunity

Identify a Productivity tracking measuring mechanism.



Learning Outcomes

Progress to date FY 17-18


Identification of Areas of Opportunity



Audits and Monitoring

Defining Best Practices

Process Mapping and Tips to optimize coding efficiency


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References

Journal of AHIMA November 2017

Journal of AHIMA October 2017

Central Learning

AHIMA

AAPC


THANK YOU FOR YOUR TIME

We welcome all questions!

[email protected]

[email protected]

Quality

Valu

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mailto:[email protected]

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Documents

HTH Iowa Project Workshop: Monitoring Coding Productivity ... · Healthcare Coding and Consulting Services (HCCS) Angela Hartman, CCS, CPC Outpatient Coding Manager Healthcare Coding