Recording every bit of a patient’s progress has never been more tedious, or more vital. It’s as true for the patient’s quality of care as it is for the provider’s bottom line.
It’s hard to imagine, but even just one instance of incorrect coding can end up costing a provider thousands in Medicare reimbursement dollars.
As the Centers for Medicare and Medicaid Services (CMS) investigates processes to ensure the Medicare Trust Fund pays for value, one focus is the coding of hospitals.
“Coders are professionals, certified in their respective fields of expertise, and their goal is code accuracy,” said Susie James, manager of inpatient coding services at Medical Management Plus Inc. (MMP), a Birmingham-based compliance company that audits inpatient records for hospitals for accurate DRG assignment. “It is difficult because coding is one singular, but vital, component of the process for assigning accurate DRGs. Other factors include comprehensive and legible physician documentation.”
The struggle is to get the doctors to document how sick the patient is, said Susie James at MMP. Hospitals commit a lot of resources for documentation programs and have staff working with physicians to help them better understand documentation issues as they relate to coding and DRG assignment.
For example, if a patient is admitted with Chest Pain, the working DRG is assigned for Chest Pain, having relatively low reimbursement; however, if the physician documents that the patient’s Chest Pain is due to Gastroesophageal Reflux Disease (GERD), the code and DRG will now reflect GERD instead, which has a higher reimbursement. A coder has to review the entire record and consider all documentation before a final DRG can be assigned.
A lot of metrics look very bad for physicians because they didn’t take time to document the appropriate treatment provided. Even if a coder knows what a doctor means in documentation, it won’t pass the litmus test for payment approval if it wasn’t documented properly.
As president of the Alabama Association of Health Information Management and an approved ICD-10-CM/PCS trainer for the American Health Information Management Association, James has learned plenty about the risks of inaccurate coding. An incorrectly reported procedure could potentially have a reimbursement differentiation of more than $15,000. For example, coding an Automatic Defibrillator instead of a Pacemaker.
James said that one of the main challenges a hospital faces is to make sure the appropriate DRG is assigned so it can receive appropriate reimbursement for the services provided. The federal focus right now is more on allocating the appropriate DRG payment, which is dependent on how sick a patient is according to a physician’s documentation. If coders see several signs and symptoms of Pneumonia documented in the record, but the physician doesn’t actually write the word Pneumonia, coders cannot assign a code for Pneumonia.
“Some companies just look at reimbursement,” James said. “MMP wants people to be compliant with rules, regardless of how it affects their money.”
TruCode – a medical coding software company that provides tools for hospital coders for assigning the appropriate DRG through integrated references, coding guidelines and rules – helps clients stay as compliant as possible, while also providing tools for appropriate reimbursement.
Prior to DRGs, people would go to a hospital for treatment, have the procedure, go home, get a bill and pay that amount, according to Becky DeGrosky, a 35-year health information management expert and product manager at TruCode. “It was kind of like taking a car to the car garage to have it fixed and he calls you at the end of the day and says, ‘I’ve fixed your car and it’s going to cost $1,000.’ PPS changed that to, the garage calls you after doing the assessment and says, ‘Your car needs XYZ widget replaced and it will cost you $1,000. Do you want me to fix it?’” she said.
“I’m a fan of the hospital,” DeGrosky said. “I don’t think hospitals are overpaid. I don’t think they intentionally commit fraud. I feel like they should always be getting as much as they can, and you can’t do that if you’re not in the right DRG. You need to be in the right DRG to maintain (financial) stability. TruCode provides the coder the tools she/he needs to make sure that happens.”