A holistic approach to ICD-10 coding compliance

March 25, 2016

With ICD-10 now a reality, overcoding can result in penalties, while undercoding can mean lost revenue. Here’s how to develop a comprehensive compliance strategy.

With ICD-10 now a reality, overcoding can result in penalties, while undercoding can mean lost revenue. Here’s how to develop a comprehensive compliance strategy.

Coding compliance is top of mind for many physician practices now due to the transition to the ICD-10 code set. With the massive expansion of the code set, providers are struggling to know the correct codes to use and the level of specificity  required. 

If practices don’t have a good grasp of appropriate coding, they could inadvertently undercode or overcode. If an organization undercodes, it may not receive all the reimbursement to which it is entitled and may even receive a denial, depending on the situation. On the other hand, overcoding could result in penalties and other regulatory consequences. 

A practice should take the time to understand what’s involved in ICD-10 compliance. Although this may seem daunting, there are resources available online, through vendors and professional organizations that can provide medical practices with the information they need to code correctly. In some cases, these resources also will highlight specific coding areas of which organizations should be aware based on the types of patients they regularly treat. 

Next, the practice must audit its current coding processes against the required ICD-10 codes and see if shortfalls exist. This can be done by internal staff or by consultants who are familiar with ICD-10. 

 

After identifying areas of needed improvement, a practice can take steps, such as additional staff training, to make sure those responsible for coding use the appropriate codes going forward.

Training can take many forms, but should include real-world examples and opportunities to practice so that these individuals fully understand what has to change and how they can change it.

To help staff retain information, practices can employ training strategies that encourage knowledge retention. For example, a practice might periodically quiz staff members on certain coding situations or have them engage in sample coding exercises. 

Finally, a practice should regularly audit its coding activities. The Office of the Inspector General recommends that a practice audit 10 visit notes per provider per year. This audit should verify proper and complete coding.

Auditing is another area where an outside resource could be helpful. In some instances, practices can send coding samples to an outside vendor for auditing and improvement advice. 

 

Step-by-step 

Developing a comprehensive and consistent compliance strategy does not have to be difficult. In fact, practices can treat the concept the way they would any performance improvement opportunity. 

 

First, they must familiarize themselves with the applicable regulatory requirements and determine a method for learning about changes or revisions to these requirements as they arise.

Next, compare current performance against regulations to identify compliance gaps. Devise a plan to respond to shortfalls and close the gaps. Often, mitigation strategies involve training, workflow redesigns or policy and documentation changes. 

Continue to monitor compliance to ensure effective. Revisit the topic until performance improves. After compliance is achieved, periodically verify performance, and shift training efforts to promote information retention, helping staff apply what they learn to everyday work processes.