How to Choose
the Right Coding
By Sarah Humbert, RHIA
HEALTHCARE HAS UNDERGONE several major upheavals in the
past five years. Many organizations adopted new electronic health
record (EHR) technology while navigating the implementation of
ICD-10-CM/PCS. In the years since the adoption of ICD- 10, organizations have steadily navigated new systems and processes.
While ICD- 10 coding productivity may not have fully rebounded to ICD- 9 levels, it is steadily increasing. In February
2016, ICD- 10 productivity was 22 percent below previous ICD- 9
rates; as of July 2016, productivity had increased to 11 percent
below ICD- 9 rates.¹ Now that productivity concerns have eased,
organizations can resume ongoing coding audit programs to
ensure optimal data and reimbursement.
Coding Audit Landscape Changing
In the years prior to ICD- 10 implementation, many organizations
focused on “hiring bodies” who had some knowledge of coding.
ICD- 10 was a new frontier and few, if any, coding professionals
had experience with the system. As a result, health information
management (HIM) departments were open to hiring staff with
a lesser skill set and providing on-the-job training. Consequently, the primary focus of coding audits during that time was to ensure coder proficiency with the new coding system.
Now that coding professionals are more skilled and familiar
with ICD- 10, HIM leaders are evaluating internal processes to
ensure high levels of coding quality and productivity. Coding
audits are now focused on what is meaningful to the organization rather than conducted in reaction to outside influences.
More frequent coding audits are now more commonplace. Best
practice involves ongoing, consistent audits focused on 3. 5 to five
percent of total volume per month. Auditors adhere to a schedule to
review sample cases every week. As part of the HIM workflow, this
routine promotes efficient mitigation of any repetitive coding issues.
Coding Outcomes Based on Method
The two main coding audit methodologies utilized to measure
ICD- 10 accuracy—per code and per record—focus on assessing
coding quality. Results can vary widely depending on the process.
Auditors look at every decision made by the coding professional.
Some auditors call it the “code-for-code” method. This approach
considers the entire coding picture, reviewing not only ICD- 10
codes, but also discharge disposition, present on admission indicators, and other abstracting items. Codes that impact reimbursement are given twice the weight of those that do not.
This is also known as the “all right/all wrong” or “
record-for-record” method. Auditors review the record and look only at
mistakes that impact reimbursement. If a mistake is deemed a
reimbursement issue, the entire record is counted wrong. This
method is very challenging for coding professionals.
Consider the following hypothetical audit for a department that
requires coders to maintain a 95 percent accuracy rate. Coders falling below 95 percent accuracy are subject to disciplinary action.
For this audit, six records were reviewed for one coding professional. For each record, 10 codes were assigned by the coder,
including two codes deemed to impact reimbursement. Each
auditor found a reimbursement-impacting error in the same
record. As illustrated in Figure 1 on page 19, the overall accuracy rate assigned to the coding professional for the audit varies
greatly between the two approaches.
In this example, with the per code method, the coding professional’s correct code assignment was determined to be 70 out
of 72 codes, resulting in a 97 percent accuracy rate—well above