The Power and Profitability of Risk Adjustment Reviews

Today's presenter is Stephani Scott. Stephani has over thirty years of experience in the health care industry working closely with physician and, physicians and staff and health information management. She has worked in a variety of settings, including hospitals, long term care, multi specialty physician practices, and EHR software design and development.

Stephani was a part owner of a consulting company for many years providing services and best and best practices for physician practice management including coding and documentation audits, compliance, and revenue cycle management. She has an extensive experience in inpatient and outpatient modeling and coding. Compliance throughout her career, Stephanie has enjoyed teaching E and M coding compliance at EMR utilization to many physicians and staff both locally and nationally.

And with that introduction, I'm gonna turn the time over to Stephani.

Thank you, Cordell. Appreciate that.

I am very excited to do this presentation today. I'm was monitoring all of those that join joined me and looking at where where you're located. It's it's always fun to get a wide range of audience. So, welcome.

For today, I wanted to talk about risk adjustment using the importance of it. There's a lot happening in the industry around risk with changes, and we really need to get ahead and get on top of that.

Part of getting ahead, we could implement previsit review. So we're gonna define what those are, some best practices and challenges that you might overcome as you start to initiate those processes.

Then we're going to talk about post visit reviews that are equally important And then we're gonna talk about different steps in closing the loop with those processes and communication.

We'll touch on communication and then we'll we'll do a conclusion, wrap up at the end.

Alright. So There's a lot of different technology, and terminologies out there around risk adjustment. So depending on where you're performing those reviews depends on the terminology and the technology that you may or may not be using. So I wanna to kinda get back to basics. So we're just gonna do, a little overview about risk adjustment and and what that end goal really is.

So over many years, a healthcare system has been shifting and involving and moving towards an incentive payment structure. So those that have that of us that have been in the industry a long time, we have seen that evolution. And so we're starting to see even more that providers are getting reward rewarded for better care rather than more care. Right?

This transition from fee to service to value based care, doesn't just change the way the physicians document and how they might get paid and doesn't excuse me, just impact the patient outcomes.

It is also changing the way we do business.

And we need to consider those changes and we need to adapt and change the way we do our coding too.

We can no longer continue to do the things the way we're currently doing. Right? The industry is evolving to a point where we need to evolve as well.

With risk adjustment, there's several different types of models out there. There's like your Mips and Macra incentive programs. There's population health incentive programs.

And of course, you've got your standard HCC risk adjustment through Medicare Advantage.

There's ACO programs, Medicaid programs, all across the country and they're unique and different depending on where you are.

So incidentally, CMS announced a brand new ace model that has, a program that that's just going on gonna go on for five years initially and it's focused on primary care providers.

So, it's a program that you have to opt in. You have to fill out an application, applications, I believe, will open up with CMS May twentieth through June seventeenth. So you've got a really short window to review that program and, apply for it. Now what's interesting in the program, I've I've got my little handout here on it. Is that CMS is offering a two hundred fifty thousand dollar upfront incentive for advanced shared savings.

K? So that's certainly something to to make note of and look into. So again, I mean, there's news like this that's constantly coming out that we need to keep, our eyes on so that we can help our business and our organizations stay abreast of all these changes.

Okay. So kind of back to the goal of risk adjustment with all of these different models, There's different measures that apply or different diagnosis or conditions that are being monitored.

And the reason why they're being monitored so closely, you know, besides improving patient care, of course, it's to identify what are the expected costs that it's that will, be required to take care of this sicker population.

Right? And those populations, like I said, could be very different depending on the area that folks live in.

And so basically the sicker the patient is the more shared saving funding that could potentially come to your physician practice or your healthcare organization.

You need to make sure that that you're just not assuming that your organizations participate. You need to talk folks and make sure that they've got contracts and agreements with these different health plans.

So the goal with risk adjustment coding is to capture and quantify that highest level of illness and condition and complexity of these patients so that we can ensure that those shared saving funds are distributed efficiently and accordingly where they should be.

We wanna make sure that through that coding, the incentives, and the rewards are a slide and aligned correctly.

And of course, all of this, the end goal is to make sure that we're providing higher level quality.

Care and we're doing it as efficiently as possible.

Alright. Capturing accurate coding is absolutely critical to every organization. It doesn't matter if you're participating with risk adjustment or not. Accurate coding is key. We can't afford to leave money on the table. There's no organization that can afford that anymore. We can't afford to do it wrong either.

Right. So we need to make sure that we're investing in, infrastructures and processes and, and everything we can to ensure accurate coding.

So there's there was a study that CMS released, in twenty twenty two.

And, I know it's a little bit outdated, but it's still meaningful, and it's gonna tell you, give you an idea of the why we have to do it right. So in this study, this came from Medicare payment advisory commission.

They reported, a data in twenty twenty one that risk adjustment scores from that that year were four point nine percent higher than regular Medicare fee schedules.

K. So the almost five percent higher They also went on to say in this article that they identified some errors in coding and those errors they did some root cause analysis and were directly or indirectly associated with, infrastructure that some of the health plans had in place for retrospective reviews.

So that overall process, there there were some issues with that.

There were errors directly linked to natural language processing or computer assisted coding, and there were errors linked to coders who may or may not have been certified.

And so some of these diagnoses weren't as accurate as they could have been. So it's a it's a interesting article. I I reread it the other day. You might wanna take another look at it. It's it's very meaningful.

So, because of that, nearly five percent increase in, risk scores, it resulted in seventeen point one billion dollars of overpayments. So Cmax extrapolated that out. That's huge. Right?

That's a ton of money. And so, they were anticipating that at the time in laws organizations, payers, hospitals, physician practices, unless they made, some changes that it could be a combined forty three point six billion dollars that could be incorrectly shelled out in overpayments in twenty two and twenty three. So I haven't heard if if that was the case yet or not. I've kind of been monitoring that.

I haven't heard that yet.

But nonetheless, that's a lot of money. And so CMS instituted because of this study the clawbacks. And so I'm sure we've all heard about those dreaded clawbacks.

And, it's it's definitely a situation where we need to make sure that our coding is accurate because nobody we can't or to have a callback. We can't afford that an error that happened in the past that we have to pay for today. That's that's just gonna cost the organization a lot of money, where we're already struggling to get ahead of the economy and get ahead of, the industry things that are happening, like, with change health care and, you know, other other and roadblocks that are just bound to happen.

Okay. I wanted to share with you, risk adjustment case study that we did we published this in twenty twenty two and this was claim data that we reviewed in, twenty twenty one. K? So although this study itself is a couple years old, I've been looking at some preliminary risk adjustment, accuracy rates from our twenty three data, and it's showing very similar results to this case study that that we did in twenty two. So it's really not far off with what's happening with today's accuracy.

So in this study, let me just give you a little bit of background. We had several different clients that we performed Machrad V audits. Four. With each of these clients, they had a fairly large sample size of two hundred to three hundred claims with these each each organization, not in total.

And we targeted mostly primary care providers, of course, but we also targeted specialties like cardiology and endocrinology and and some of those specialties that are commonly seeing patients for those chronic conditions that risk adjust. So we made sure that we we targeted those specific specialty. So there really wasn't, you know, outliers in involved in the study. So our study results showed an overall overall accuracy rate of sixty two percent for ICD ten risk adjustment codes. This is terrible. That's a that's a terrible score. Right?

It resulted in in some over coding and some under coding. So, you know, opportunity across the board.

Some of the over coding errors we identified as as we started to take a a deep dive and do root cause analysis was that the documentation, we could see some of the chronic problems addressed maybe in HPI or maybe pulled in from a problem list, but we didn't see meat. We didn't see that those conditions were monitored, evaluated, assessed, and treated. Right? So in most instances, it was obvious that the provider was thinking about those conditions. It just didn't get documented in enough detail for the those codes to be actually coded on the plan.

And then we had excuse me, fourteen percent, it just incorrect code. That was where the specificity was incorrect. So the code category was correct. Just not the level of specificity.

And then we had a five percent of added code. So if we look at the over coded and then the opportunity specificity and the added codes, that's about a fifty fifty percent split error rate.

You would think that that would just wash out, but it didn't. When we, took a deeper dive and we did a financial impact, We actually found that, there was an overall benefit of a hundred and sixty thousand dollars of missed revenue opportunities.

How we came up with that is, you know, there's an average value of the eight CC categories. And so at the time, it was two thousand five hundred dollars. And so, you know, we came up with that, that estimate, and then we applied that with the, comparison of the HCC categories that were either incorrect or the ones that were under coated that could have been a higher, and that resulted in the the missed revenue of a hundred and sixty thousand dollars. Now these groups, of course, they had to, you know, those were shared savings with the health plan, but still, that's a lot of money. And we're seeing very similar results with our twenty three data.

So we know that the best solution to ensure quality patient care and financial success through accurate Cody you need to incorporate medical chart reviews, right? Not foreign to us. We we know that. But when it comes to risk adjustment, what kind of reviews are best? What should we to be doing? How often should we be doing these reviews?

How do you possibly find the time to do them in your already busy, crazy schedule? Well, let's talk about some of those answers and see if we can help with with that.

Alright. As I mentioned in the beginning, there's a lot of different terminology used around risk adjustment and sometimes this terminology is used interchangeably for different types of reviews that are done at really different points in time. And so I created this slide deck with the hulk to maybe add some clear vacation, on on some of these terms that that we just commonly throw out. So a pre encounter review is basically done before the patient is being presented to, the physician office, being seen by the physician. Right? We often refer to that as a prospective clinical review. So perhaps you've you've heard that.

For today, we're going call it a pre visit risk adjustment review.

The concurrent review is happening as close to the point of care as possible. So, basically, as soon as that provider sees the patient and the documentation's complete, review is happening. Sometimes it's called a pre claim coding review or a prospective coding review or sometimes we hear prospective audit for today's session, we're gonna call it a post visit review.

Okay.

Some other reviews that might come into play is post encounter. So those are basically the retrospective reviews that are often associated with health plans, particularly care advantage plans.

And then we have our audit audits are, definitely the retrospective reviews where we're taking a sampling. We're not looking at mass plan data. We're doing sampling like your Machrad B audits or the Medicare Red B audits that they're submitting to you any, anytime we're investigating or or doing follow-up after education sessions, we might, and, include those those periodic audits. Okay.

Let's do a poll real quick.

I wanted to see out of everyone that is attending, does your organization conduct any type of previsit reviews? So, Cordell, I'll ask you to help launch that poll question.

You got it. It's been launched, but we'll wait till we get about fifty to sixty percent participation. So we got a decent sample set.

Oh my gosh. We've got a lot of responses.

What do you think, Cradell? Do you think we're good to go?

We just hit sixty. I'll share the results.

Alright. So the majority of the audience today are performing pre visit reviews. This is awesome. I love to hear that.

About five years ago, I had a prediction that I felt like risk adjustment was going to move from retrospective reviews more closer to the concurrent review more closer to the visits actually happening. And I'm am just thrilled to see that a lot of organizations, are are doing just that.

Alright.

Okay. Let's dive into previsit reviews.

One thing that I taught my kids when they were young is you should always do things right the first time so you don't have to fix it later.

I think that that is so true and absolutely everything that we do whether it's work or personal, it is far better and less stressful and more cost efficient if you do it right the first time than if it's, not done correctly and we have to fix it and maybe refix it and, you know, you could lead to a lot of a lot of problems on the back end. So, revisit reviews, I think, is is an area where we could definitely apply that. So let's really define what a previsit review is. It's basically a review process that is intended to help the positions prepare for their upcoming visit with a patient.

There are two types of previsit reviews. There's the clinical staff evaluation or review that they might do, and then there's a certified coder review, that that could happen, usually around risk adjustment, but but not always.

When we're talking about pre visit risk adjustment reviews, it's really important.

The most successful practices that incorporate the clinical staff and the coder review together, they have the best success and best outcomes.

So I wanted to talk about, well, what are the benefits of a clinic, or rather a clinical pre visit review?

You know, obviously, we wanna make sure that these patients that are their health their health services are more complex. They have a lot of complex conditions.

Maybe coming to the office is not just a matter of showing up, there's preparation that potentially could take place beforehand that could help expedite that visit. So doing these, preclinical review visits, we can identify, okay, who's coming in. What do those patients need? Do they need special equipment or their special drugs that we normally don't have on stock, but we've got a pre order.

Are there interprets interpreters that need to be in place? What about strongmen? If we are having to transfer patients out of their wheelchairs and whatnot.

So it's really good to to identify all those clinical needs beforehand and and have them ready to go. That's going to reduce the wait times. Right? As soon as something isn't going like clockwork, it's just gonna grind a halt to your office Right?

So having that stuff in place is really helpful.

The other thing, that the clinicians can do is identify any potential health risks. Right? So from previous visits, did the patient follow through with having, their tests done.

Did they take their medications? Are they compliant?

Did they see other physicians that they needed to other specialty physicians, things like that? And is there any coordination of care that should have took place that perhaps didn't that then can be addressed during this this upcoming visit.

So I really look at these clinical and risk adjustment previsit reviews like baking a cake.

You can decide, hey, I'm gonna go ahead and bake a cake and you get in the middle of it and all of a sudden you find, hey, you don't have some of the ingredient the key ingredients that you need. If you're out of baking soda, your cake may not rise and and turn out the way it should. If you're baking cookies, what if you don't have any chocolate chip cookies? Your cookies are not gonna be as good as they could be. So, you know, doing these things in advance of the visit is is just gonna ensure a a better sweeter outcome.

Alright. Let's talk about the benefits of a coding previsit review. This is where the coders are coming in.

And they're identifying any gaps in the overall documentation and coding process.

And in turn, what that's going to do is really reduce the burden that the physicians have on the day that they're seeing that patient. And trying to get their documentation completed and and off. And so the coder is really key to Review the medical record documentation, identify these previous gaps, and then communicate them, identify them somehow possibly work with the CDI team and or clinical staff to ensure that that those gaps are addressed and closed that next coming visit.

That's, it's going to help the physicians maximize reimbursement.

It's going to avoid any over or under coding.

Very similar to the the case study that I mentioned earlier implementing these previsit reviews can help reduce those coding errors significantly.

So for example, Those of you that do risk adjustment coding, know that depression is a common diagnosis that is often coded incorrectly. We often see depression as just unspecified depression.

Well, in most risk adjustment models, the unspecified depression doesn't risk adjust.

But if there's a higher level of specificity associated that diagnosis, then all of a sudden, it's part of an HCC category, which does risk adjust. And so, you know, just because of an unspecified condition and documentation that has some gaps. Maybe this provider and organization is losing a lot of money.

So those are areas that that you can shore up. Social determinants are really important for our ACO models and those are often either forgotten or left out of the note and and not realized.

They're just very deep in the record. So we gotta, you know, the coder can kind of bubble up those situations to the physician so they can be addressed timely.

Insuring these previous reviews will not only reduce those coding and documentation gaps but it can also ensure more accurate payment so that not only can it reduce denials but maybe, you know, prevent, penalties that might come from RAV V reviews that might hit you later on.

Okay. Before beginning this pre visit review process, you must first identify your targets, your targets of specific diagnosis and conditions that you wanna look at and target for your process.

Okay? I love Steven Covey. He's one of my my favorite people to quote, he, has a famous saying begin with the end in mind. Right? If you know where you're going, you're gonna have a better understanding of what you need to do to get there, and you're gonna end up in the right place.

And so that's so true. It's just like, you know, if we're gonna bake that cake, make sure you have all your ingredients in place ahead of time. So make sure you've got your target. So we can't do everything possible that's out there, but we certainly can identify what our gaps are and target those low hanging fruit items, so to speak. K? So if you if you've done an audit in the past and you identified, certain HCC conditions that aren't being captured or documentation issues then you can list those as your your targeted areas so that, when you're doing your pre visit, review that process can go faster.

You know, if you haven't haven't done any of those baseline, steps, you might wanna consider that. So once you've identified the specific HCC gaps or documentation gaps that you want to address, then you need to target your providers.

You can't possibly audit every provider, every patient visit, but you can identify you know, some of the the providers and the types of visits that will be most fruitful for you to review during that process.

Sometimes, you know, you might wanna take a deeper dive in and alter your your target as you go depending on what you're are finding. So for risk adjustment, the most advantageous, providers are your primary care specialists that that see those chronic problems at risk of dust. Maybe your annual wellness visits or your biannual visits.

Maybe if you've got visits where patients are just being followed up from a hospital event.

There could be some new conditions or worsening that would provide higher level specificity or some new coats So those are the types of visits that you want might wanna consider.

Timing of when you start to look at these visits is is important too. The sweet spot is maybe two to five days because that's gonna give you, all of that historical information most relevant to that patient.

Top of mind with the clinical staff and with the provider.

Some organizations, have a buffer of two weeks to give them some room and time. To make sure they can get through this process.

I would not recommend beyond thirty days because let's face it with these these this patient population, there could be medical events that happen that could alter what you the work that you did with your previsit review. So you need to find out what that sweet spot is for you and your organization.

You need to have a list, prepare a list of the different types of, document patient that you want to review and how far back are you going? When was the last time you did a previsit review? If it was, you know, months ago, great. You you know, you can go back that far.

If you haven't gone gone back, recently, you might wanna consider twelve to eighteen months. Right? And so all of these different focused areas and targets you want to develop and align in advance so that you can set. Like, if, for example, if you're going to do an eighteen month look back because you've never done a previsit review, you might want to give you, more time than just two days before the patient visit.

Right? So all of those things need to be considered so you can structure this really well organized targeted, effort.

Alright.

Oops. I think I advance this slide too quickly. Yep. Here we go. Alright. Communication is key. So once the coders have done this previsit review and they've identified these different opportunities.

They need to communicate that. Right? And The best way to communicate those opportunities and findings is to share that information using the existing workflow tools that you have. So most EMR systems have a great either alert system or provider query process or some type of messaging process. If you don't, you might want to work with your, IT folks and your EHR vendors to see what's out there.

So that you can utilize those tools and be really efficient with it.

What those messaging systems does, it'll put it in the provider's regular work queue and or alert messages. So they're gonna see those. It's it's, highly unlikely that that they'll be able to, not not see them and and not realize that that they're there when it's in an existing workflow.

The other thing that you could do is join the clinical huddles.

Right? If, your organizations are not having a a clinical huddle either the day before or the morning of the patient visits, it's they're highly valuable, very informative, very helpful. It's gonna make your all overall day go a lot smoother.

And the coder has has that opportunity to say, hey, wait. You know, here's some things that do need to be addressed.

The physicians have a responsibility as well. Right? They should be an active participant in these previsit reviews that they should to the best of their schedules can manage be part of those clinical huddles review, their their messages, and their work cues to make sure that they're reviewing that information and, know what needs to be addressed before these patients come in.

Perhaps in helping the physicians with their responsible responsibility in this program is make sure that we're scheduling so it gives them enough time to breathe and enough time to look at at these work cues throughout their day so they can make sure that they can address that. So just a little tip that that we've learned the hard way.

Alright.

So that's a lot. Pre visit reviews are very, time intensive, and there are challenges with this process for sure. Anything we do in health care is challenged Right? It's never easy. If it was, we we wouldn't be here. We wouldn't have jobs.

So what we did is, we identified and working with with are subject matter experts that do this and some of our clients that that we've done these previous visit reviews with. We identified in ranking order, what some of those challenges are. So staffing is by far the number one challenge. Right? It is hard to make sure that you have all of the staff necessary perform these previsit reviews.

If if you want to implement this process, the best thing that you can do is maybe do a pilot.

Okay. Identify, a targeted provider, a group of providers, carve out time for your your staff, both clinical and coding, you know, come up with with your target and your plan and do a pilot for maybe a month or so or maybe a couple weeks and then assess the results and I guarantee you you're gonna see a return on investment.

If you don't, then maybe your targets were off. But if you do it right, you absolutely will see that return and then you can that to your CFO and your compliance folks and your practice manager. And then you can begin to be able to to to blow out and grow your pre visit review program.

And over time, of course, you wanna just incorporate, a check to make sure it's working the way it should.

You need to make sure in this process that you're utilizing all the technology that's available to you or identify technology that could be incorporated to help you. Doing this process manually is very, very time intensive and very costly.

I've got a section that we're gonna talk about some of the technology that could help you with the process.

Time is a constraint. You gotta carve it out. Make sure that everybody's on board. So you can do that process. You gotta make sure you have the right coders.

Not every coder, is gonna be able to grasp the vision of these previous at reviews because sometimes in the previous at reviews, you've gotta look at lab values and diagnostic tests to identify gaps and conditions. Right? As a coder, we're not gonna you know, assigned diagnosis codes, but we certainly know how to analyze a medical record. We know what should be documented. We know and or could be easily trained on what to watch for from a clinical perspective so that we can then identify those gaps and communicate. So having making sure you have people with the right skill sets important.

Make sure that you've looked at your provider workflow and your EHR system for communications to make sure that they're they're going going to be easy to utilize and not put extra burden on the the providers during this process.

That's a lot. Let's go over post visit reviews.

Okay. The definition of a post post visit review is where a coder is reviewing the medical record notes. In applying the proper ICD ten codes that are associated with HCC risk adjustment, pretty straightforward. We do that all the time. Right?

But this is done in real time before the claims are being submitted to the payers.

Okay? So as close to that visit as possible, and the more that we see coders in incorporating the HCC process more closer to that front end.

The higher accuracy you're gonna get with a coating and the more and better responses you're gonna get from your providers when there are gaps identified. Right? Because not only are we gonna see gaps pre visit, we're we're definitely gonna see gaps post visit. Maybe some inconsistencies or maybe something that that Coder identified before wasn't actually addressed, different things like that. And so we we need to move that process up as close to that concurrent review as possible.

And then, with those findings, we're obviously going to be educating the providers on the back end of where those missed opportunities fell. There's clinical benefits.

K. Most of the clinical benefits for post visit review is really associated around quality assurance or clinical documentation improvement, which we know is constantly has been happening in the hospital forever.

We're starting to see that in the outpatient setting more and more and more, which I love to see that. A lot of population health, rural, community clinics, even big practices, they're starting to incorporate those clinical reviews for quality assurance, and incorporating c d CDI into their groups.

It's great. It's a really good way not only to identify conditions that need to be reported through health statistics, but it's also to get a pulse on our providers, overworked and overburdened and their for, they're they're not able to document everything in the visit.

You know, because you're you're doing these reviews, and it's kind of like a a root cause analysis in some bet. And so you're gonna identify different workflow gaps, right, not just documentation coding gaps. They're gonna identify clinical workflows.

And so they can make those adjustments or, you know, correct anything clinically very quickly and it's going to preserve the the positive outcomes of those patients.

There are definite coding, benefits from it as well.

Coders are gonna validate that coding. The claim is gonna go in a hundred percent correct. Or nearly a hundred percent correct.

It's gonna be processed. It's gonna, make sure that, any under coding is addressed beforehand, any overcoating, and it's gonna eliminate denials. And hopefully, if there's a RadV review that comes up your organization is gonna pass with flying colors. So, again, it's all about doing things right the first time up front so that you've as an organization, you've got that peace of mind and you're ensuring you're not leaving money on the table that you're capturing those dollars.

Particularly those risk adjustments shared saving dollars upfront.

If you've got a pre visit and post visit review process in place or or one or the other, that gives you negotiating power with your payers.

Some of those health plans that are that you're participating with risk adjustment for, you can go in and you can start to negotiate negotiate rather maybe a higher percent of that shared savings.

Maybe there's there's other things that you can negotiate because you've got this and if you if a if it's a proven track record, you've got that negotiating power. Very powerful tool there.

Just like the pre visit reviews, post visit reviews does require a targeted focus. Right? You've gotta identify those particular issues, that are low hanging fruit for target capture. Maybe you've got a particular provider or area or specific codes that you've identified that are con consistently unspecified, you know, whatever it is, like make sure you're you're coming in with that target.

The difference in the process is at at this point in time you can leverage technology to help you with There's a lot of different options out there.

Technology is a great tool as long as it is done correctly.

So for example, one of my risk adjustment quality folks told me a story that I wanted to share. She was re reviewing a medical record, and it was, in an EHR system that had a combination of templates as, as well as voice recognition. And she was reading the note. She was getting down to to the, plan of care that said renew prescriptions for x y z and chicken sandwich, no onions, no tomato, and homestyle fries on the side. And then the note continued on, with a plan and then it was signed and closed out. So that became a permanent part of the medical record.

You know, obviously those things happen. We're all human But if we're doing these re post visit reviews before those claims go out, then we can definitely incorporate corrections that that could happen and need to happen, to ensure the accuracy. We can look at, the documentation to ensure that there is meat that these conditions have been monitored evaluated assessed and treat.

We can correct any inconsistencies and then we can make sure that things are coded correctly and of course educate the physician again. Communication is key.

Post visit reviews are best when there's timely communication of those missed opportunities back to the provider.

A common way to do that is through physician queries if something is inconsistent or the medical record needs be amended.

Communication is really important and, physician query is a easy efficient way, to make sure that that happens, implementing a CDI program in your outpatient, Eric.

Outpatient.

Clinics is also a good way. And you'll want to make sure that you're including root cause analysis. Right? There's things maybe it's an EMR template you or EMR workflow issue has nothing to do, with coding. So those things can be easily identified during this communicative process.

Physiciansicians also have a key responsibility in the post visit review process Right? They need to make sure that their medical record documentation is timely. So if we've implemented previsit reviews and we've improved the efficiency, decreased our patient wait times. That's going to lessen the burden of the physician and hopefully allow for additional time to get things documented and ordered and showed up, you know, as, you know, before the next patient or by the end of the day so that they're, not missing any documentation or anything that needs to be in the note. Right? That's gonna be lot easier for our for our providers.

But that's not foolproof. Right?mistakes do happen. Many organizations shy away from amending the medical record, but you need to remember that CNN has said healthcare providers must ensure thorough and a comprehensive documentation to support prospective refuse efficiently.

In essence, information that, is or rather, if essential information is missing, it can impact the accuracy and validity of the claim and impact the patient's care.

Therefore, the medical record should be amended.

So they're on board. If there's something Orion, the note, it's okay to mend it and and get that corrected.

There are very similar challenges to the pro post visit reviews. The order is a little bit different.

Staffing is the number one, but we have found in our process of doing post visit reviews that oftentimes the EMR either workflow that the physician is doing or the output statements or something with the templates or something in that when arrived, whether it was miscommunication or communication.

Oftentimes there's delays in getting the medical record documentation shirred up.

And it just that, you know, delays the whole process and really, you know, makes it challenging to to get this process done. And then we see that a lot of organizations really aren't taking advantage of the different technologies that are available.

Alright. So, let's talk about closing the loop through physician queries. I've mentioned that throughout this presentation.

And I wanted to, provide you with some additional insights am how to properly implement physician query process. So the HIMA has a great definition.

A physician query is a communication tool or process used to clarify documentation in the health record for documentation, integrity, and code assignment for an individual encounter in any healthcare setting. Okay. So it's no longer just a facility DRG workflow process. It's the physician query process is something we should be incorporating no matter if we're doing risk adjustment reviews or other types of of audit.

We wanna make sure everything's is is documented and coded right the first time so that there's a right way to query in a wrong way. K? So I just very quickly wanted to go over this. We shouldn't just bombard the physicians with a ton of questions and queries.

Right. They're going to get very frustrated with us, they're not gonna answer. As coders, we need to do our due diligence, we need to exhaust all resources, review the medical record, do everything that we can. And if we do find something that is missing, and and here's a short list of examples, then we can query.

Here's some other examples of when we can query if there's conflicting information. For risk adjustment, we often see, items in a problem list, but and maybe there are drops down in assessment with but we don't see a correlating plan. So we don't have that meet.

Sometimes it's not clear, is it is there, cause and effect relationship? Is it historical or is it active Those are all, most common areas that we might see, in risk adjustment that we might need to query. Another one would be what if we've got some abnormal lab values that could be associated with a chronic condition that risk adjusts. Right? If you've got coding guidelines that allow the coders to review those and just query the provider. That's perfect. It's acceptable.

You can verbally talk with the provider, but it needs to be somehow memorialized in the medical record account. Right?

Organizations look at the entire medical record, not just the physician. No. So those queries should be and must be part of the patient's medical record.

We can't lead the physicians. We need to stick with facts Here's a lab result, here's medications, here's exam findings, you know, things like that.

We should never in our query say, hey, if This is coded. It's it will there's a financial impact, associated that we can't lead the physician in any of those types of ways. We just need to be very fact and make sure the documentation is is as accurate as possible.

Alright. Let's talk about technology Here's a quote that I love from Ben Walker. The role of medical coders has advanced dramatically in the last few decades with the arrival of encoders specialized software programs that assist in choosing coats. With this technology, the coding process has been streamlined and at see in patient records has been enhanced significantly.

One of the reasons why I really love this quote is not only is that all true.

But Ben Walker is a CEO of a transcription outsourcing company.

K? And I found it very interesting that to hear that him talk and to read some of his, material as articles and things that are out there He's a guy that gets it. He has embraced technology.

You know, transcription, you could argue it's it's a, dying art. Right? But not really. Right? He embraced the technology, and looked for different opportunities for his company to still be successful.

And he he's a very profitable in offering these transcription service not just in healthcare, but in other areas.

But it it's very true. We need to embrace. Right? The evolution of the way we do things is changing.

And we need to change our businesses and adapt.

So technology can play a role in the pre and post visit review process. There's a lot of different things that you can automate.

Through claims data, you can automate your gap lists.

Rather than manually looking for those gaps yourself, a lot of that could be automated now. If you've got a great relationship with your, health plans, have them provide you with a gap list.

Save you the time and effort. You know, have them provide that. We know that they have that data. Right? Just ask for it.

There's other technologies and and processes like the physician query process can take save time and money there's using, other technologies, to assist with coding or the encoders. That's gonna help the coder speed up the process instead of thumb and throw a book, it's much faster to to use that technology.

Technology should be used in a way where it's gonna help the coder and the clinical teams work smarter rather than having to work harder.

So there's analytic data that can be ran and presented to the clinical and the coding staff in advance and some of that's kind of your gap or your suspect codes.

But there's analytic data that you can run on your own within your own organization.

Just talk with your CFO about that. Maybe your organization can hire a statistician that can lend some numbers for you as well.

You know, don't feel like just because you're over HIM or or you're a coder auditor that this process is a hundred percent burden on you, involve everybody so that you can participate in, their support in implementing some of these tools like an analytic tool or some type of a review.

Natural language processors and other AI tools Hey, I I think they're great as long as they're utilized correctly. Right? Natural language processing has been around for quite a while. And in risk adjustment, oftentimes the threshold is turned down way low And so it's presenting to the coders massive list of conditions that really shouldn't be coded. They could be symptom conditions, they could be conditions that are historical rather than current. And so you wanna move that threshold bar if you're using natural language processors.

To an acceptable list that's manageable. Right?

Same with AI.

AI has been evolving over the last couple years. It's amazing, but with AI, it's a predictive technology and their hallucinations.

Meaning that oftentimes based the AI technology is predicting coding when really it's it's not in the medical record. So again, you've gotta work with these tools and adjust that threshold.

But embrace it. Right? These tools are never gonna take over for a coder.

It's gonna help the coder to work with validate what really needs to be validated rather than reading every single word in the note. Right? So you've gotta view it as like a little angel on your shoulder or a coding buddy that's gonna help, but make sure that that you're implementing, some reviews of that technology to avoid any potential up coding, to avoid any CMS clawbacks.

Okay. Encoders are great. I've got a snippet of codify. That's what we use.

But there's a lot of systems that are awesome out there. You need to find one works good for your organization.

Sometimes, you know, the organizations make decisions and we're left with, you know, the decision. Well, embrace it. Identify how to incorporate these encoders into your your day to day workflow, figure out everything all the features in those systems, how to use them. Maybe there's, some inexpensive links and integrations that could be put in place of these systems within your EHR system and that standard workflow that maybe could help the providers as well as as the coders.

Not one technology is is gonna get you over that hurdle mitigate some of the challenges. It's it's gonna be, a wide range of different efforts of support as well as different technology solutions that you could potentially incorporate.

Alright. That was a lot of information just in conclusion.

Performing pre and post visit reviews is is a lot of work.

We realize that. We've done it. We've lived it. We know it. But I promise you if it's done right, it you will find over time, you know, just a matter of a couple weeks to a month you're going to increase the overall efficiency of your practice.

Right? You're gonna have a powerful impact on decreasing wait times, improving workflows, lightning the physician burden, and oh, that's gonna reduce your denials. It's gonna reduce any, clawback penalties that that might come up. And, you know, give you peace of mind that you're gonna be rad food rad v ready.

Right? You're gonna be able to pass those reviews.

And it's gonna result in more accurate and potentially increased risk scores for your patients and your population and will allow your organization to participate in those shared, cost savings.

Alright.

Cordell, do we have A few minutes for a question or two?

Yes. I think we have time for, maybe one, two or three depending on how quickly you can answer them.

Let's see. The first one, can you apply pre visit reviews to other types of services, or is this only applicable to risk adjustment services?

That is a great question.

Absolutely you can perform previsit reviews.

So those of us that have been, in the industry for a long time, if you remember the transition from paper records to electronic health records.

We did look at, the medical record documentation before patients we're seeing in the EHR, right? And so we perform those previsit reviews. We kind of shored up problemless and different things like that. Well, now that we've been on electronic health records for a long time now.

A lot of times, those pre visit review aren't being done anymore. Problem lists are back to garbage, right? Garbage and garbage out.

Those problem lists are key to ensuring an efficient process for the provider.

You know, if if they're inaccurate, the provider may not know or pay attention to the details of those diagnosis codes. Right? They may not have time to update them. So performing these previsit reviews and working in time with the clinical staff to ensuring your problem list are accurate is not only gonna help risk adjustment, but it's just gonna help your overall accuracy for any type of a visit that that you're performing within your organization.

And then of course, the the post visit reviews, are essential for all types of services. How much and how often you do it, that's up to your organization.

Alright. We'll do one more question.

Before wrapping up, that is, do you have a demonstrable ROI on performing pre and post visit reviews?

That is a great question. We have one particular client that, they're basically doing post visit reviews, and we're we're helping, we provide the coding staff. They they've implemented some technology, that overlays their EHR system that helps with that post visit review. So our coder then goes in and they utilize that technology, which helps them streamline it.

It helps target the, visits that need to be reviewed and those conditions. And they they correct the coding right there before the claim is is initially sent out the first time to the health plan. With that project, I I can't divulge a ton of information. Obviously, it's confidential, but I will tell you that it has been wildly successful We're to the point where it's very, very efficient for the one, specialty group with multiple providers.

It's less than a full time coder that's managing that.

And they're seeing huge benefits cost return on the shared savings with their, risk adjustment health plan that they're participating with. So, and it's significant savings. I will tell you it's similar to the savings that we saw from that case study that I shared with you.

Okay. Thank you so much stuff, and thank you to everyone in attendance today. And that brings us to the top of the hour, so we're gonna end it there.

Just as a reminder, we tomorrow, we will be sending out a copy of the recording, and the slide deck for your, safekeeping.

And please feel free to share that with, others in your organization that you feel might benefit from it. There will be a quick survey if you're interested in learning more about Stephanie and her team's audit and coding services, once we close this out. So feel free to, let us know if you're interested in talking to us. Thanks again, Stephanie. Thanks again to the audience. We will see you next time.

Thank you. Take care.