Symposium spotlight: Avoid coding calamities inherent in provider self-coding

Editor’s note: Laurie Prescott, RN, MSN, CCDS, CCDS-O, CDIP, CRC, and Shannon McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CRC, CCDS, CCDS-O, HCS-D, will present “Eeeny-Meeny-Miney-Mo: Picking the First One is a No! The Pitfalls of Provider Self-Coding” on Day 1 of the ACDIS Symposium: Outpatient CDI, which takes place November 14-15 at the Hyatt Regency in Austin, Texas. Prescott is the director of CDI education and McCall is the director of HIM and coding for HCPro, a Simplify Compliance brand, in Middleton, Massachusetts.  

ACDIS Blog: What’s the biggest risk of providers self-coding their records? What are the most common mistakes?

Prescott: Providers often “self-edit,” meaning they won’t report a condition because they don’t feel like they directly treated it. They may not understand that if they take a patient’s condition into consideration in choosing medications or treatments, that medical decision-making process counts toward code assignment. For example, let’s say the physician sees a patient for a drug-resistant urinary tract infection (UTI) and reviews medications in order to choose the less renal toxic one due to the patient’s chronic kidney disease (CKD) or follows prescription guidelines for renal dosing. If the provider only reports the UTI and fails to report the CKD, that leads to a missed coding opportunity and I see that as one of the biggest concerns with provider self-coding.

In this same scenario, the provider may choose to report the UTI as being unspecified and fail to also add the additional code to identify the infectious agent. Again, this is a missed opportunity that can support the patient’s higher medical complexity.

McCall: One of the biggest risks that I see comes from a lack of actual coding training and reliance on automated tools in the EHR for diagnosis and procedure code assignment (especially for subjective codes like evaluation and management [E/M]). Physicians either do not fully assign all required codes for a condition or don’t capture co-existing conditions that were relevant to the encounter, albeit not the reason for the visit.

ACDIS Blog: How can CDI professionals tell that these mistakes are occurring?

Prescott: CDI professionals need to work closely with coders and assist in auditing efforts to review provider notes and assigned codes. This will help them identify trends and teaching opportunities to assist the provider in future documentation.

McCall: One of the best ways to tell that there’s an issue is when your risk adjustment factor (RAF) score is lower than expected. Additionally, you may see higher levels of E/M services reported for minor presenting problems.

ACDIS Blog: How can CDI leaders make the case to the organization’s administration to hire dedicated coding professionals rather than relying on the providers?

Prescott: Organizations often have providers self-code because it saves money in the short term. Recently, however, I have visited organizations that are hiring more coders due to the results of retrospective audits which quantified missed opportunities and illuminated the hidden costs of physicians’ coding errors. So, conducting a retrospective audit should be a starting point but CDI programs should also be delving into denial trends as well.

Don’t expect a whole system change, but if audits find costly trends within a specific population of patients the argument could be made for additional physician education, CDI involvement, and greater coder oversight related to that specific subset of records.

The other factor which is harder to quantify is provider satisfaction and burn out. Most physicians do not wish to code the record—they want to care for patients. How much physician time is being spent coding? A time study might be useful.

McCall: If you identify the coding errors and missed opportunities, you’ll be able to show a loss of revenue, which can be very compelling for an organization’s administration. Also, the industry is moving more towards quality reporting rather than solely encounter-based. So, missing important codes which illustrate the true severity of the patient could be detrimental to the physician’s (and the physician practice’s) quality ranking.

ACDIS Blog: Some people have said that providers resist having coding taken off their plates. How should CDI professionals present the change to them to ensure buy-in?

Prescott: I have never heard that from a provider, but I would assume they are speaking to E/M code assignment. I would explore why the providers are resistant and speak to the fact that the coding of a record requires a team effort.

McCall: In my experience, most providers don’t want to do their own coding. They’ve been forced into it due to sheer magnitude of encounters for provider services and not being able to employ enough qualified coders to code each and every encounter.

ACDIS Blog: In the event that an organization resists adding dedicated coders, how can CDI staff help providers code their records accurately in the meantime?

Prescott: Education! Audits and education! Feedback and education! And lastly, availability—they should know how to provide timely advice and guidance.

McCall: Prepare the providers in advance for upcoming encounters whenever possible to ensure they know what co-existing conditions should be supported in the documentation but ONLY if truly applicable. Many providers don’t know which conditions really affect reimbursement since it varies by setting. Take morbid obesity for example. The condition isn’t classified as a CC/MCC on its own (E66.01) in the inpatient setting but it’s important in the outpatient/provider setting since morbid obesity (E66.01) does fall into a hierarchical condition category. 

ACDIS Blog: If you could have dinner with anyone, alive or dead, who would it be, and why?

Prescott: My dad—he was the wisest man I have ever known.

McCall: My grandmother, Alice. She was the best cook I’ve ever known. I would do anything to be making homemade biscuits with her again.