Guest Post: Using coding, CDI to transform hospitals’ revenue integrity, part 1

by Amber Sterling, RN, BSN, CCDS, and Jana Armstrong, RHIA, CPC

Most healthcare systems already have a proven process in place to monitor revenue integrity and ensure correct reimbursement. More than 60% of hospital executives believe revenue integrity is essential to their organization’s financial stability and sustainability, according to a survey by Craneware, Inc.

But does revenue integrity extend beyond charge masters and billing? Kalispell Regional Medical Center (KRMC), one of the “100 Great Community Hospital” according to Becker’s Hospital review, says yes.

For KRMC, revenue integrity focuses on three operational pillars: clinical coding, CDI, and physician education. At KRMC and many other health systems, revenue integrity is a three-legged stool:

• Knowing what to do (furthering education)
• Knowing how to do it correctly (entering coding data)
• Justifying those decisions (providing complete and accurate clinical documentation)

The three areas work together like a well-oiled machine to build a strong revenue integrity model. Since 2014, KRMC has used TrustHCS for outsourced coding, auditing (coding and CDI), and education (coding, CDI, and physicians), though not always concurrently. Identifying and targeting the three pillars of revenue integrity allows KRMC to ensure each area not only meets department-specific goals, but learns to work in concert with the others.

KRMC’s focus on education and continual improvement holds valuable lessons for other organizations ready to take revenue integrity to the next level.

Step one: ICD-10

In 2014, KRMC began ICD-10 education for the coding and CDI teams. The training covered anatomy, physiology, and the expected code changes by major diagnostic category (MDC).

The scope of work broadened when KRMC decided to train a new interventional radiology (IR) coder and transition its outpatient and emergency services coders into same-day surgery coders in preparation for ICD-10. Training focused on three key objectives:

• Gain a greater breadth of skills by training all coders in all aspects of ICD-10
• Pinpoint which DRGs would shift as KRMC moved from ICD-9 to ICD-10
• Broaden coders’ skill set by mastering CPT and modifiers

Coders were broken into groups of 10 for in-depth training on one specialty at a time. Trainers looked at specificity and acuity, what kinds of information coders would need going forward, and how queries would change with ICD-10. The process was systematic, with group training providing several benefits:

• Coders learned the same categories together
• Coders trained on the same cases
• Coders reviewed accounts they were working on as a team

By working as a team, KRMC quickly identified coding trends and strengths and weaknesses.

TrustHCS conducted remote audits of the IR and outpatient staff. Records were reviewed daily, with weekly check-ins and further education provided via telephone.

According to Christine Seager, RN, BSN, CCDS, director of CDI services and ICD-10 project manager for KRMC, “Accuracy is the single most important strategy to making sure that we are painting a clear clinical picture of our patients. Education is the key. It facilitated continuous education, feedback, and communication to ensure our ability to be successful in the ICD-10 transition and the strengthening of our team.”

With coding training complete, a thorough clinical documentation audit was next in line.

Step two: Clinical documentation audits

KRMC had a mature CDI program in place and was already using computer-assisted coding. In the fall of 2015, the organization worked with external auditors to conduct a CDI audit and identify areas of improvement based on the recent ICD-10 code changes.

“We had a seasoned CDI team and our providers were receptive, but ICD-10 was an unknown,” she says. “We needed to capture all documentation for specificity, accuracy, and completeness.” Only about 14% of the cases audited revealed additional opportunities. CDI recommendations were referred back to Seager, who then distributed these results to the leadership team. KRMC demonstrated favorable results in CDI and was in good shape to move forward with the third foundational component of revenue integrity: physician education.

Step three: Physician education

Between January and April 2015, KRMC spent 12 days focused exclusively on physician education. Trainers provided the medical staff with information about changes and DRG shifts in ICD-10. As a result, physicians learned to accurately communicate with CDI specialists and coders to ensure accuracy on the front end of the clinical documentation process.

Seager found presenting the modules in a clear and concise manner, maximized physician time. They used post-training resources, a quick reference guide for each specialty, and an email address for questions specific to ICD-10. Seager attended each training session as a local resource, answering questions about KRMC procedures. “Not only was this helpful for the CDI team, but also helped streamline the process for physicians,” she says.

Editor’s note: To read the second part of this article, return to the ACDIS Blog on Friday. Sterling is the director of CDI services for TrustHCS, where she consults with clients to develop and improve CDI programs. Armstrong is the executive director of consulting for TrustHCS. She received her bachelor of science in health information management from Arkansas Tech University. This article originally appeared in HIM Briefings. Advice given is general. Readers should consult professional counsel for specific legal, ethical, clinical, or coding questions. Opinions expressed are that of the author and do not necessarily represent HCPro, ACDIS, or any of its subsidiaries.