Complexity of coding requires special coding staff or in-house expert
Education for expert and entire staff essential for accuracy
With an average of 300 new codes and the development of guidelines that change the way old codes are applied each year, it is critical that your agency keep staff members up to date on coding requirements to ensure that you receive the highest appropriate reimbursement, say experts interviewed by Hospital Home Health.
While codes and guidelines are published in October and November of each year for implementation in January, coding inservices should not be limited once a year, especially since updates can occur throughout the year, points out Judy Adams, RN, BSN, HCS-D, COS-C, a home care clinical consultant with Larson, Allen, Weishair and Co. in Charlotte, NC.
Home health agencies approach coding in different ways, says Adams. "Some agencies have the initial clinician assign codes at the time of the assessment along with the diagnosis," she says. "Other agencies have the clinician assign the diagnoses in order; then a coding staff member assigns the codes.
"Studies have shown that 96% of every assessment requires some change in the code assignment," states Adams. "These changes can include use of a code not supported by the diagnosis, use of a code that makes an incorrect assumption about the cause of the condition, or inaccurate sequencing of codes," she says.
Because coding has become so complex, Adams says she sees more agencies moving toward using a specialized coding staff or coding experts as backups. Many agencies designate one or more staff members as coding experts who not only serve as the "go to" person or people when clinicians have questions, but they also stay on top of changes in coding requirements and audit their own agency's performance, she says.
"The expert does not have to be certified as a coder, but he or she does have to be passionate about coding and interested in staying current," she says. "Attendance at coding seminars and having current guidelines and manuals is essential for this person."
"We have the nurses who are completing the OASIS do the bulk of the coding," says Stacey Benner, RN, HCS-D, staff development coordinator for Family Home Health Care in Columbia, KY. While clinical managers and Benner review claims before submission to verify codes, the agency took steps to reduce the number of coding errors made in the field two years ago by redesigning the new clinician orientation to include a basic coding course, she says. The basic course covers issues such as how to determine primary and secondary diagnoses and codes and highlights codes that are most often used incorrectly, she explains.
The eight-hour course was not only presented at orientation for new nurses, but initially all nursing staff members had to take it. "We presented the course at all of our offices until every staff member had attended," she says. It was important that everyone take the course because everyone needed to hear the same information, she points out. "Now we offer the course only once each month for new nurses or for nurses who need a refresher."
Attendance is mandatory
Attendance at the basic coding course is mandatory but the agency does pay staff members for attending, says Benner. "Our clinicians are paid on a per-visit basis; so I was not sure how we would handle paying for their time, but the benefits to the agency outweigh the cost of paying them to attend," she says. Not only do clinical managers spend less time correcting errors but also the agency is reimbursed at the highest appropriate level, she explains. Benner tried to make the daylong course interesting with interactive activities and games. (For tips on making coding classes appealing, see box below.)
Typically, clinicians don't like to sit for eight hours at a time listening to a teacher; but the staff at Family Home Health Care in Columbia, KY, have found that even a topic such as coding can be fun. The first thing the agency does offer to make the eight-hour basic coding class more appealing is pay for the day, says Stacey Benner, RN, HCS-D, staff development coordinator for Family Home Health Care. It is hard to mandate a course, then ask the staff member to take it on their own time, she adds. "We also offer contact hours for the course," says Benner. Because nurses must obtain continuing education credits to maintain their license, the ability to attend a mandatory class and get the hours they need for their license is a real bonus, she points out. Once everyone is in the class, Benner uses a variety of techniques to keep the class lively. "We play Jeopardy and Family Feud during the day to review material we've covered," she says. "I make sure that questions used in the game are questions that they will see on the post-test at the end of the day." Repetition of the information throughout the day in different forms increases comprehension, she points out. In addition to coding classes, Benner also keeps staff members up to date on coding changes, tips, and common errors through quarterly meetings with OASIS nurses and e-mails to all clinicians. "I also send coding quizzes to all staff members by e-mail and they return to me," says Benner. "These short quizzes are a quick way to identify educational needs related to coding." |
Coding accuracy improved after the basic coding course was offered but Benner noticed that nurses were having trouble with V-codes. "I developed a more advanced course that addressed V-codes and all staff members attended that course," she says. Now, the advanced course is offered every other month.
Just offering a coding course isn't enough to guarantee an improvement in coding accuracy though, Benner points out. "We do a pre-test and a post-test for the course to determine how effective the class is and how well the nurse understood the material," she says. "We also have several pairs of eyes looking at all of our coding before we submit claims and I conduct audits on different offices to see how clinicians are coding."
While the clinical managers are finding significantly fewer errors, their review serves two purposes, says Benner. "Not only do the reviews give us a chance to correct errors before claims are submitted, but the reviews give us a chance to identify trends in errors that indicate a need for more education," she explains.
If it is an individual that seems to struggle, then the nurse is sent to the basic coding class again, says Benner. If the problem seems to be more widespread, then Benner will go to the office and offer an inservice to the full staff, she says.
There are some codes that routinely cause problems, says Adams. "Wounds are very difficult to code because there are so many different types of wounds and often the nurse has minimal information," she says. The key is not to make an assumption that just because the wound appears to be a trauma wound, it was not caused by something else such as surgery, she says.
Diabetes poses the same type of problem because there are so many different manifestations of the disease, says Adams. "We treat a lot of diabetic patients in home care, but before you list diabetes as the primary diagnosis, be sure that the plan of care supports that as the diagnosis," she says. If the plan of care describes treatment that is not related to diabetes, then the primary diagnosis cannot be diabetes, she explains.
While it makes good sense to have your coding expert or clinical manager review coding to ensure accuracy, be sure that your process to change codes meets standards set by the Centers for Medicare & Medicaid Services (CMS), says Adams. "An area that most agencies have problems with is actually a condition of participation requirement that says agencies must have a written procedure to correct codes," she points out.
Not only should your policy identify the review or audit process, but it should also explain the steps to take to change the code, suggests Adams. "The best practice is to identify the original clinician as the only one who can change a code but you need to address situations in which the original clinician is not available," she says. The person who notices an error during review should contact the original clinician to discuss the code and get more information if needed.
If the clinician agrees that the original code is incorrect and agrees to the code suggested by the reviewer, then the clinician can give consent to the change by phone, e-mail or in person, says Adams. "Be sure to document what the change is, why the change was made, and who was involved in making the change," she says. "It is very important to document these details so that you don't appear to be making changes simply to increase reimbursement," she adds.
Although hospital-affiliated agencies may have access to more coding experts than freestanding agencies, it is important that a home health agency have its own experts on staff, Adams stresses. "There is no one that knows the home health business like your own staff so you will get the best coding from a home health expert."
Sources
For more information about coding challenges in home health, contact:
- Judy Adams, RN, BSN, HCS-D, COS-C, Clinical Consultant, Larson, Allen, Weishair and Co., 101 North Tryon Street, Suite 1000, Charlotte, NC 28246. Phone: (919) 960-6739. E-mail: [email protected].
- Stacey Benner, RN, HCS-D, Staff Development Coordinator, Family Home Health Care, 705 Wright Drive, Columbia, KY 42728. Phone: (270) 384-2345. Fax: (270) 384-0740. E-mail: [email protected].
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