By Chris Dimick
Even small departments may never experience complete harmony in their assignment of codes, but they have good motivation for achieving as much consistency as they can. Training, communication, monitoring, and coding reviews help reach that goal, HIM experts say.
Coding manager Julie Bajer recently asked six different coders on her team the same coding question-and got six different answers. Each of the answers was correct.
Coding professionals know that the act of coding is not black and white-there is room for interpretation. A coder's background and training, among other factors, will greatly influence the way he or she assigns codes.
"Coding is much more of an art than it is a science," says Bajer, MSA, RHIA, CCS-P, the HIM operations coding manager at Group Health Cooperative, based in Seattle, WA. "So [coding professionals] definitely have a lot of room for interpretation."
And while varying interpretations may each be legitimate, maintaining consistency in the way individuals code is a high priority in coding departments. If coders get out of synch in the logic they apply in coding, the inconsistency can lead to lowered facility reimbursement, possible audits, and even affect patient care.
Achieving consistency can be a struggle for small facilities and large enterprises alike. Whether six coders work side by side within a department or 26 coders work remotely across several facilities, training, communication, monitoring, and reviews will help keep coding consistent, say HIM experts.
The Persistency of Inconsistency
Coder interpretation is a large factor in inconsistency.
"There is some subjectivity in coding, so I think you can have two coders code the same encounter differently," says Kathy Dorale, RHIA, CCS, CCS-P, the vice president of health information management at Avera Health, based in Sioux Falls, SD. "It disturbs me when people think they are a coder after learning a little bit about it. They tend to think it's like using a dictionary-not that difficult.
"However, a coder doesn't just use books and resources, they also have to use their head, use their logic, their common sense, to make some decisions." Other factors that cause coders in a department to code inconsistently are their exposure to different methods of training in school, habits they picked up at previous jobs, and a lack of understanding certain updates or rule changes.
Subjectivity aside, the biggest reason for inconsistency is a lack of universal education on certain aspects of coding.
For example, if a coder is unclear on coding rules or does not feel the need to seek additional information when necessary, inconsistency can occur, according to Carolynn Childs, BA, RHIT, coding manager at Mercy Medical Center in Des Moines, IA.
In this case, the coder is not coding to the more specific diagnosis, which can affect reimbursement, quality measurement, and patient care. "Consistency is a high priority [at Mercy] because we don't want denials," Childs says. "We want everyone coding consistently and having the same information so that our bills get paid accurately."
Inconsistent coding could be an indication that a facility's coders are not assigning the proper codes or are undercoding, which leads to lower reimbursement.
Reviewers who find inconsistent coding within a facility may be more apt to investigate further and deny claims, Dorale says. For example, if coders are using modifiers incorrectly, that could raise a red flag to Centers for Medicare and Medicaid Services auditors, Bajer says.
From a managerial perspective, coders who code accurately and consistently can better help each other in their work, Bajer says.
"If they are all coding the same way they can answer each other's questions the same way, or I can answer their questions and know they are all getting the same information," she says.
Computer-assisted Coding Improves Consistency
Coding automation tools such as computer-assisted coding (CAC) can be used to improve coding consistency.
Without CAC, coders code off the chart from scratch. With CAC, the application selects codes that coders then review and possibly edit. The coders take on more of an auditing role.
Since the CAC system offers consistent codes, there is less room for human error and diversion, says Kozie Phibbs, MS, RHIA, the territory sales manager with CAC vendor Digital Voice Systems, based in Tampa, FL.
Of course, auditing CAC-suggested codes is an integral part of using CAC. Judgment calls made by coding professionals are still a factor in determining correct codes, but CAC makes the automated code referral process more consistent within a coding department.
CAC also enables coders to expand their auditing capabilities, Phibbs notes. CAC can be used to analyze vast amounts of coded data and look for trends in coding inconsistency. The system can show managers how coders are changing or auditing computer-recommended codes. If upon review these changes are determined to be errors, the manager can pull the electronic information and use it to train the entire department.
Having watched the technology in use over time, Phibbs has seen a trend of fewer inconsistencies in coding. "[Users of CAC] are getting fewer denials, fewer charts are being bounced back from the billing department, and auditing is coming in and they are seeing that the numbers just aren't as skewed as they used to be," she says.
Ensure Consistent Training
The best way to ensure coding consistency is through the even and routine disbursement of information and education among a coding team, as well as regular audits and coding reviews, Dorale says.
If all coders receive the same education and training, in theory they will all approach coding in the same way and remain consistent.
Avera Health is a large integrated health system in the northern Midwest, consisting of dozens of clinics and 28 hospitals across five states. Dorale works in the system's central office, providing HIM and coding support to Avera's healthcare facilities.
As part of their corporate services, Dorale and her staff work with Avera's 72 hospital coders and dozens of clinic coders to provide compliance reviews and ensure they remain consistent in their coding.
Maintaining consistency across a multistate healthcare system can be challenging, Dorale admits. Her main tools are organization-wide education sessions, compliance reviews, and open communication.
Each year Dorale's staff educates the entire system on coding changes, such as CPT updates and ICD-9 revisions. If any coding rule changes pop up throughout the year, Dorale will compile them and send off an educational update to Avera's coders.
The system-wide training sessions ensure all coders receive updated information at the same time, therefore maintaining consistency.
Throughout the year as coding and billing guidelines change, Dorale will send out e-mail blasts informing HIM directors, business office staff, compliance officers, and coders of the changes.
Maintaining coding consistency sometimes requires one-on-one training. Stumped Avera coders can send coding questions to Dorale's central office staff, which strives to provide an answer within 24 hours. Centralizing answers in this way ensures the same responses are given when similar questions come in from across the system.
If Dorale's team remains consistent in the training and information they provide, by extension so will the coders when it comes time to use that training on the job.
When inconsistency between coders is the result of one person coding incorrectly, proper education can close the gap.
Audio seminars are a big part of the training at Mercy Medical Center. Coding staff are required to attend the sessions, which Mercy purchases about seven times a year. These updates keep staff consistent by ensuring everyone has the most up-to-date information, Childs says.
Audit to Identify Inconsistencies
An important tool for ensuring coding consistency at Avera has been regular site visits conducted by Dorale and the central office staff. The corporate HIM department reviewers visit Avera hospitals and clinics on a routine basis to review chart documentation, coding, and billing practices.
At the end of a review, the reviewers meet with the facility coders to provide guidance on how to improve their coding. A written report is also sent, which coding managers can use to further guide their staff. Since every facility is reviewed, reviewers get a sense of the common inconsistencies and mistakes made among coders in various states. If a trend is identified, Avera central office staff will put out a system-wide communication instructing all facilities on how to correct the problem.
"If I come back to a facility on a follow-up visit and see the same error over and over again, I will know the coder is not grasping the coding rule. At that point, I will take the opportunity to spend more time with the coders to ensure they understand the rationale behind the coding rule," Dorale says. "The mere fact that we share across all facilities, across different states, and across different contractors who might have different rules, I think helps us be consistent and code correctly."
Site visits are particularly important when Avera contracts to manage a new facility. Regular reviews are conducted to ensure the coding is consistent and on par with the rest of the Avera facilities. The reviews "are there to help them learn and make sure they are doing things right," Dorale says. "We don't want them to be afraid when we come into their hospital. We want them to say, 'Oh, they are here to help us. Here are our questions. Have you been seeing this in other facilities?'"
Focused reviews are also conducted at Avera to ensure all coders are consistent. If the central office learns that a specific code or DRG is being heavily scrutinized by federal entities, they will pull records from each facility and see how that code is being processed. Central office staff will then produce a report on the results of the audit and share it with the affected hospitals and the entire system.
Providing widespread feedback helps reach staff who may have had a similar case in the past and wondered what to do, Dorale says.
Routine coding audits are a common way facilities check for coding consistency.
Quarterly coding audits are conducted at Group Health and West Boca Medical Center, based in Boca Raton, FL. Any inconsistencies or common mistakes that are revealed by the audits are shared at the organization's monthly coding meetings.
At Mercy Medical Center, a recent coding audit revealed that outpatient coders were not being consistent enough in identifying patient histories in their codes. For example, in coding for cardiac or coronary type diseases, coders were not picking up on patient history factors listed in the chart, such as smoking and diabetes.
As a result, Mercy developed informational training on the documents coders need to seek out in order to assign those particular codes consistently. A few months after the training, the audit was again conducted and showed coders had greatly improved, Childs says.
Check Educational Sources
Some inconsistency between coders can be attributed to bad information.
Dorale notes that in the past, coding workshops run by unqualified coders have come to the South Dakota area. The information discussed there can be faulty, and if Avera coders attend, they may bring inaccurate information back to the system.
Staff from Dorale's department have attended seminars to monitor the guidance being shared. If something incorrect is promoted at the event, Dorale's staff will know to watch system-wide for the mistake to show up in their coders work.
Coding managers should monitor the sources their staffs use to obtain coding advice.
If staff is using untrustworthy resources for coding help, it could both throw off the coding consistency of their department and negatively impact reimbursement. "We always back up our guidance with rationale that comes from trusted and official resources," Dorale says.
At Group Health, which has 25 coders in the department, Bajer stresses to staff the importance of using credible references for coding. If one coder uses the Centers for Medicare and Medicaid Services Web site for coding guidance while another uses a coder's personal Web site, the information they will receive could be inconsistent, Bajer says.
Keep Cheat Sheets Current
When Bajer started as coding manager at Group Health earlier this year, one of the first things she did was check the coding staff's personal "cheat sheets" to ensure they contained accurate, up-to-date, and consistent information.
Coders often keep coding rules, tips, and advice on a sheet they can readily access for help in coding. But if these sheets contain inaccurate information or vary between coders in a department, then coding will be both inaccurate and inconsistent. "All coders love their cheat sheets," Bajer says. "So I took a look at those to make sure they were correct."
Upon first review, many of the sheets contained out-of-date or inconsistent information, Bajer says. Correcting the sheets with the coders was a quick way to ensure more consistent coding among them.
Bajer's department is currently developing authorized cheat sheets that will be distributed to all coders, each specific to their area of coding. A staff member will be appointed to update the sheets as coding requirements change, as well as add additional information upon request.
At Mercy Medical Center, which has 17 coders, informational cheat sheets were inserted into the facility coding manual to help coders consistently interpret the code suggestions and documentation from specific staff physicians. This type of cheat sheet is especially useful in CPT coding, says Childs, Mercy's coding director, which relies on heavy interpretation of physician reports.
Gather Staff for Discussions
Periodic staff meetings are a great way to ensure coding consistency, Bajer says. The meeting can be used to discuss common questions and relay advice the entire team can use.
Coding meetings take place every month at Group Health, where various topics are discussed. In March, a physician discussed evaluation and management documentation, which gave the staff shared insight into how documentation reflects actual clinical care.
At Mercy Medical Center, bimonthly coding roundtables are used to address coders' questions and ensure coding consistency. The meetings serve as a forum where coders can get perspective from their peers by asking questions such as "I've coded this case this way-is that correct? Do you code it in a different way?" Childs says.
Outside of the meeting, staff members are encouraged to discuss questions with each other and send feedback on the unfamiliar issues they experience. Childs then shares these experiences, along with commentary on the right way to code, with the entire group.
Promote Open Communication, Centralize Answers
Open communication might be the simplest way to ensure coders in a healthcare facility remain consistent. Outside of staff meetings, coding departments find other ways to share questions and answers.
At Group Health, Bajer sends out a weekly coding newsletter to staff. In addition to general department information, she highlights common coding mistakes she has witnessed.
"If I see one or two coders making a mistake with their encoders, I will put it in the newsletter and say, 'Just keep in mind, when you are coding this type of chart, you need this code.'"
Monitoring questions helps disseminate consistent answers. When a coder comes upon some gray area in assigning codes, the urge may be to ask a coworker for advice. However, even though the coworker may provide the correct information, the information is only being passed from one person to another. Bajer encourages her staff to send all coding questions to her first. That way, she can ensure the advice given is consistent and based on official coding resources.
This reporting up of coding questions also allows the coding manager to monitor education needs. If many people have the same question, the coding manager can work the information into department-wide training.
Good communication is especially important when coders work remotely. Of the 25 coders at Group Health, 21 work from home. When coders are in-house, a coder with a question can stand up and ask their next-cube neighbor or walk into the manager's office for an answer. But staff working remotely often e-mail their questions, which may not convey a complete picture of the situation and the question, Bajer says. In addition, questions and answers exchanged via e-mail may not be passed along to other coders in the department.
Communication with physicians through queries is also essential to maintaining consistent coding, says Kristi Calin, CCS, a coder at West Boca Medical Center in Boca Raton, FL. One of 10 coders at her facility, Calin admits that "I can take my chart, code it one way one day and then the next day, code [it] a different way." The reason could be incomplete chart documentation.
For example, Calin says, take a chart documenting congestive heart failure and hypertension. There are different levels of congestive heart failure and different levels of hypertension that could change the code assigned, she says. "If there is not complete documentation, it can put that [code] on either side of the fence. That is where physician documentation really is what maintains our consistency with the coding."
When the coders at West Boca Medical Center come across a coding gray area, they are quick to query physicians for additional documentation or information. "I don't usually allow gray areas in coding, just because that is where we would get audited," Calin says.
This process gives the group a consensus on the proper code.
"Communication is a big part of being consistent," Calin says.
Tips for Keeping Consistent
- Ensure Consistent Training
Provide all coders with the same education and training; roll out information on updates to all staff at the same time
- Audit to Identify Inconsistencies
Conduct regular audits or reviews; address inconsistencies and errors with focused training
- Check Educational Sources
Monitor the sources staff use to obtain coding advice; ensure all coders use credible, official sources for guidance
- Keep Cheat Sheets Current
Ensure staff's personal "cheat sheets" contain up-to-date and accurate information; consider creating authorized sheets for the facility's coding manual
- Gather Staff for Discussions
Use periodic staff meetings to discuss common questions and relay consistent advice the entire team can use
- Promote Open Communication, Centralize Answers
Encourage staff to send all questions to the coding manager, who can monitor trends and share the answers with the entire staff through newsletters, meetings, and specialized training if necessary
Chris Dimick (firstname.lastname@example.org) is staff writer at Journal of AHIMA.
"Achieving Coding Consistency"
Journal of AHIMA