It is time to perform an assessment of your facility or practice in order to evaluate your ICD-10 progress and to uncover potential issues that might affect productivity, risk, or cash flow. Also, by conducting an assessment, you can identify opportunities for improvement, additional training needs, documentation assistance, or operational changes necessary to benefit your organization.
A good method of conducting your assessment is to use key performance indicators. Some of the key critical performance indicators include:
- Code frequency
- Coder productivity
- Volume of coder and/or provider questions
- Use of unspecified codes
- Physician or non-physician practitioner productivity
- Clinical documentation versus ICD-10-CM code selection
- Increase or decrease in number of queries
- Claims denial rate
- Payment amounts by payer
- Medical necessity pass rate
- Discharged not final billed (For hospital inpatient services)
- DRG volumes by group (ICD-9 versus ICD-10, for hospital inpatient services)
- Clearinghouse edits
- Payer edits
- System issues
You don’t have to assess everything at once. Take a few of the key performance indicators listed above and develop a method for assessment and communicating feedback to administration, physicians, staff, etc. The Centers for Medicare & Medicaid Services (CMS) has developed a very useful ICD-10 Next Steps Toolkit that can be obtained online at cms.gov/icd10. Let’s review a few of the key performance indicators:
Clinical Documentation versus ICD-10-CM Code Selection
Run an ICD-10 coding frequency report to identify how many times your top 10 codes are reported for each physician and/or provider. This can be the baseline for reviewing documentation and coding to ensure that specificity is achieved and the documentation supports the services reported. Once you run the report and identify the ICD-10 codes that have been most frequently used since Oct. 1, 2015, you should begin reviewing the coding and documentation for each individual provider on a random basis. Performing this review by specialty does not really identify the problem areas by provider, so it has little value if not performed for each individual provider.
When reviewing documentation, identify the following:
- Does the medical record support a selection of a specific ICD-10 code?
- Is the documentation complete?
- What additional documentation is necessary to select a code to the highest level of specificity?
- Are there diagnosis codes missing on the claim?
- Was the ICD-10 code selected accurate, or is the code selected unspecified?
- Is laterality documented in the medical record, if applicable?
- Who selects the diagnosis code(s)?
- Does technology play a role in the selection of the diagnosis code?
- If software is used, is it accurate, or are their some inconsistencies?
Once you review the documentation by provider, you will be able to determine whether the documentation accurately reflects the correct diagnoses reported on the claim. You will be able to assess whether the practitioner needs additional education or training and what type of training might be beneficial. If you uncover inconsistencies in technology that you use, it will be important to find reasonable solutions to correct these inconsistencies.
Another key performance indicator is coder productivity. Did you measure productivity prior to ICD-10 implementation? If so, now is the time to assess if productivity remained the same, improved, or is now falling short. When assessing coder productivity, identify how many records per hour typically can be coded, and do so by type of encounter. For example, coding complex surgeries would take longer than coding an evaluation and management service. Set new goals for productivity and monitor progress weekly and monthly until productivity improves. This should be an ongoing process.
Volume of Coder and/or Provider Questions
Do the coders now send more queries to clarify or support the documentation and coding? Do the providers now have more questions related to the selection of the diagnosis codes? One of the questions I always get asked by specialists is “do we need to document and code co-morbidities as well as the condition being managed?” It might be time to draft a policy as part of compliance in addressing this issue.
Many providers who now are reporting accidents, injuries, and poisonings are getting confused by which seventh character to report (and the rationale behind the seventh character. You should monitor and track questions, as these can be key indicators of where additional training is necessary to successfully code with ICD-10.
Use of Unspecified Codes
Does your frequency report indicate that there are significant numbers of unspecified codes being used? Could this be an audit risk area? This might also trigger the need to audit a sampling of claims by provider.
Keep on Top of Your Cash Flow
It is important to assess and monitor the number of days from the time a service is rendered to claims submission, as well as the number of days after claims submission the claim is paid.
Are you monitoring your denials and reviewing your remittance or explanation of benefits to identify any changes in reimbursement or medical necessity denials? Have your claim denials increased or decreased? If denials have increased, what is the reason? Is the increase in the denial rate specific to a particular payer, or across all payers? If you are using medical necessity software, what is the current pass rate in comparison to pre-ICD-10? Are payers requesting additional information?
It is important to assess the number of charges or claims you submit per day, to keep track of any requests by payers for documentation or additional information to process the claim, as well as to monitor any payer and clearinghouse edits. In addition, make sure you monitor incomplete or missing charges as well as missing ICD-10 codes on orders.
So remember: now is the time to identify your key performance indicators and periodic provider assessment in order to ensure you are on top of the ICD-10 transition.
Once the assessment has been completed, what do you do with the information you have gathered? It is important to share this information throughout the organization and to provide feedback to the administration and/or physicians.
- Identify what additional tools might be helpful.
- Highlight specific workflow or cash flow issues.
- Identify additional training opportunities.
Create an issues list, whereby new issues can be addressed and current issues can be identified.
Also,develop next steps on how to solve problems and improve coding, productivity, documentation, specificity, and most importantly, cash flow.