Published in the October 2015 issue of Today’s Hospitalist
OCT. 1 HAS COME AND GONE, and the only coding classification that HIPAA-covered entities are now allowed to use is ICD-10. So what does being on the other side of this long-looming deadline mean for health care and for hospitalists?
ICD-10 has dominated the headlines for months, but don”t expect the topic to disappear just because the deadline has passed. The reality is that ICD-10 is not an event or a one-time switch.
Instead, it’s the start of a new standard, one that comes with some risk for clinicians. Odds are that no one has seen their hospital implode or huge computer- system glitches leading to “downtime.” But hospitals will need to keep an eye on many metrics to see how the transition is going and adapt to changes.
How can hospitalists help? By making sure their documentation captures all the needed specificity to describe patients’ severity of illness, and by promptly responding to queries from coders or clinical documentation specialists.
Hospitalists are seeing a growing number of inpatients and are often involved in cases as consultants where the specialists may not be as diligent in their documentation.
This is an opportunity for hospitalists to show their value by truly capturing disease specificity, where appropriate. This will greatly help inpatient coders quickly finish cases and reduce the amount of time before claims are submitted. Hospital CFOs and financial leaders will be tracking this metric, which is known as the DNFB (discharged not finally billed).
As most hospitalists have learned by now, severity of illness has a big impact on the diagnosis-related group (DRG) or type of DRG that a patient will be clas- sified under. The more accurately illness severity and comorbidities are captured and documented, the higher the payment to the hospital.
Doctors shouldn’t feel intimidated or overwhelmed by this added specificity. After all, it is clinically relevant, and it doesn’t represent changes in diseases. For the most part, it’s information that doctors already know about patients that just needs to be appropriately documented.
Hospitalists have a role to play through their own documentation. They also can influence other providers by educating them or showing best practices for documentation. On occasion, they may want to clarify with other providers the specifics around a particular procedure or intervention.
Because this is a new change for everyone, coders and clinical documentation specialists aren’t accustomed yet to the new classification system. This is particularly true for ICD-PCS, the coding system required for inpatient surgeries, which is complex and entails a lot of training.
As a result, you’re probably receiving an unusual number of queries from coders and clinical documentation specialists for clarifications. Keep in mind that they are trying to adapt to the coding system as quickly as possible and avoid denials.
Hospitalists can help by responding to queries promptly. In some cases, they may also need to amend their notes or discharge summaries. This will improve their performance on another metric that the financial types are tracking called DNFC (discharged not finally coded). Health information management (HIM) departments across the country are looking to hospitalists to be their advocates with the rest of the medical staff and to ensure that all clinicians work collaboratively with coders and other HIM personnel.
In most groups, hospitalists submit their own visit-level codes for each encounter, along with ICD codes to support those claims. Despite all efforts to obtain full payment, the medical claims process is still plagued by denials.
Most denials are avoidable or are due to submission errors, and it’s a significant administrative burden to sort through them and appeal. Although a submitted claim may not come back as a full denial, payers may request additional documentation to justify where the services took place or why physicians entered particular codes.
These types of denials can be overturned, but they still present a delay and eat up additional resources. Here’s an important specificity to remember: the laterality of a disease or condition, such as a right or left site of skin infection or a right or left hemiplegia. This type of information is almost always clinically available, and failing to include it makes a claim for denials.
As the nation adjusts to ICD-10, hospitalists have an opportunity to further prove their value and understand the elements of a revenue cycle that is being closely monitored. Now is the time to engage with hospital leaders.