Valued Voice

OVERVIEW

Accurate, complete encounter documentation and appropriate encounter coding are fundamental elements of a comprehensive Professional Services Coding and Documentation Audit and Education Program.

Developing, implementing and executing a program of this complexity can be a daunting undertaking, but the reward of maximizing and positively impacting patient care revenue, provider productivity, financial sustainability and corporate compliance is well worth the effort.

Read below to learn which elements of a program HSG’s coding and documentation experts find most important, and how they can be applied to your teams.

PROGRAM COMPONENTS

There are several foundational components to consider when developing your comprehensive program:

1. Initial General Education Session

An initial education session when starting the program is needed for new providers who code their own patient encounters and should be a standard part of the onboarding process. Many practicing providers have a limited understanding of professional services coding processes because, historically, they received limited training on this crucial topic during their education and training programs. Even as some training programs are now incorporating more coding education, competing priorities and a lack of immediate applicability and direct feedback hinder the impact of these efforts.

Completing a general educational session when the program is initiated and during new provider onboarding helps to impart a basic understanding of the coding and documentation criteria, ensuring at least a baseline understanding of the 2021/2023 criteria and processes. These sessions create a common mental model and emphasize the importance of the coding process, establishing a firm foundation for future documentation and coding interactions.

2. Performing Audits

Chart audits need to be performed to compare encounter documentation with the corresponding ICD-10 and CPT code selection on submitted claims. The documentation must fully support the assigned CPT, HCPCS, and ICD-10 codes for the encounter.  

• The initial audit tends to review a greater number of encounters and should ideally include at least a small sample from each relevant area of the provider’s scope of practice and visit types, including procedures, to offer a comprehensive overview of coding performance. Providers who practice in both the inpatient and outpatient environments should have encounters sampled in each area. Other potential target areas include encounters associated with modifiers or bundling/unbundling. 
• Subsequent audits tend to review a lesser number of encounters and could target specific practice areas, appointment types, or areas initially identified as having the greatest opportunity for improvement. This approach allows for more extensive sampling and offers a more in-depth educational experience.  

3. Individual Education

Adult learning theory predicts that general educational sessions which are not directly linked to daily experiences tend to yield incomplete and transient retention of the information – even when reference materials are provided. (This explains in part why some of the training programs, mentioned earlier, are not as impactful as on-the-job education.)

The most reliably lasting impact is realized with frequent, critical review of individual performance with timely, specific 1:1 individual feedback and education with practical, actionable suggested interventions. Reported observations and recommendations span all aspects of the audit – ICD-10 code selection, CPT code selection and documentation improvement suggestions. These educational performance feedback sessions delve into and emphasize specialty-specific elements involved in the coding and documentation process.

4. Ongoing Updates

Scheduling follow-up audits along with individual educational feedback sessions reinforces previous recommendations and invariably uncovers new territories to discuss. The frequency of follow-up audits tends to depend on the degree of individual improvement opportunities and the receptiveness of the individual and the organization but undertaking an audit and feedback cadence of every 3-6 months is common.

PROGRAM IMPACT

Maximizing professional services coding and documentation performance improvement directly impacts several key areas:

• Patient Care Revenue
• Productivity Measurement
• Corporate Compliance
• Coding and Billing Process

CONCLUSION

Maximizing coding and documentation accuracy has historically been undervalued and under-supported in many employed provider networks. The impact – both positive and negative – can no longer be ignored. We must embrace this aspect of practice operations as a critical sustainability issue and pursue corresponding investments pursued.  

When you’re ready to evaluate your organization’s coding and documentation programs, reach out to Terrence R. McWilliams to get started.

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