Blog Post February 7, 2018 Is It Time to Review Your Coding and Compliance Programs? Mitigate Risk, Reduce Cost, and Improve Productivity Authors Ben Colton In the past, coding and compliance programs relied heavily on manual processes and review of code selection to ensure proper coding occurred across the organization. But those processes were tedious and inefficient. Now, advances in technology can enhance an organization’s coding and compliance programs to help mitigate risk, reduce cost, and improve productivity. With continued reduction in reimbursement, increase in audit scrutiny, and complexity of ICD-10 coding, organizations now more than ever need to focus on integrating technology into coding and compliance programs. By reviewing the following common coding and compliance processes, you can assess your own technology gaps and focus on areas of opportunity within the revenue cycle. Code Selection: Using Technology to Maximize Productivity and Accuracy As we’ve seen, integrated EHR systems continue to empower providers to select their own diagnosis and billing codes to promote a streamlined process and reduce provider charge lag. However, with this change there comes an increased risk that busy providers are not selecting the correct codes or fully documenting the encounter for maximum reimbursement. To further complicate matters, payer rules and state-specific requirements can change rapidly, often resulting in missed codes/modifiers or increased denials and organizational A/R. To maximize provider productivity and increase accurate code selection, organizations should first review EHR system capabilities to determine what code selection tools are available. While many systems incorporate some form of code selection functionality, others may need to integrate with a third-party solution tailored to fit the needs of the organization. Additionally, for complex or challenging procedures, organizations should consider routing those encounters to a certified coder using custom work queues to increase accuracy and reduce physician burden. In either case, the implementation of the solution should be done in a way that is easy for the provider to use while minimizing interruption to patient care to increase usage and provider benefit. Coding Review: Using Technology to Mitigate Audit Risk and Maximize Reimbursement Technology can also assist in code selection during the midcycle, where additional tools can be leveraged to catch improper coding prior to claim submission. Some useful tools include system built-in claim scrubbers that use a rule-based engine to identify coding issues, third-party claim scrubbing solutions that can integrate with an existing system, or additional computer-assisted coding (CAC) and natural language processing (NLP) technology that can interpret a chart and identify missed coding issues or opportunities. While many practice management systems incorporate standard claim edits or flags to catch common coding issues, it is important to review and update existing logic to account for changes in specialty or payer-based rules to catch avoidable denials. Custom rules can be used to have coders actively monitor high-risk code selection or review probationary providers to further mitigate audit risk and maximize reimbursement, but creating custom rules isn’t the last step in the process. Workflows and team structure should also be aligned to ensure custom rules are routing to the correct team for resolution. Like A/R teams, coding teams should be structured in a way to standardize work and increase productivity. Audits, Education, and ComplianceOn the back end, technology can be leveraged in the often-overlooked audit and compliance programs and during provider education initiatives to increase productivity and tracking. Historically, many organizations have resorted to using spreadsheets and shared drives to assist in audit and compliance programs, as EHR systems have limited functionality built into the system. Fortunately, there are solutions to assist with organizational audit and compliance programs in managing, tracking, and providing feedback on annual provider audits. In certain instances, these solutions include provider education tools to distribute educational material and track usage throughout the organization, so careful thought should be made when choosing an audit and compliance technology tool. Maximize Your Efficiency: Comprehensive Reviews to Increase SuccessSimply reviewing your coding and compliance technology can be beneficial for an organization. However, the greatest benefit is gained through a comprehensive review of the workflows and processes used across coding and compliance functions to identify specific areas where technology can be used or optimized to support existing operations. Through this comprehensive review, it’s possible to identify areas to significantly reduce costs, mitigate compliance risk, increase provider and coder productivity, or generate additional revenue for the organization.