General Surgery Coding Alert

Understand the benefits of regular self-audits.

Comprehensive clinical documentation is the cornerstone of quality patient care, accurate reporting, and sound financial management. However, clinical documentation improvement (CDI) is often put on the back burner because of high patient volume and time constraints placed on overworked staff.

If this resonates with what your general surgery practice is experiencing, we’re here for you with some advice from our experts. Streamline your CDI process to make it painless and profitable by focusing on these key areas, and your practice will be back on track in no time.

Include All Staff Members in Training and Education

While one-on-one training is helpful when trying to troubleshoot specific communication breakdowns, there are huge advantages to including all staff members in documentation training. “It creates an opportunity to identify misunderstandings,” explains Jacob Swartzwelder, CPC, CRC, CIC, CEMC, AAPC Approved Instructor, managing director at Compliant Approach Partners, LLC in Las Vegas. “When everyone in an office, department, or clinic receives the same training, it can help identify discrepancies that need to be escalated to an expert,” he continues.

Additionally, proper documentation impacts coding, patient care, and overall practice operations. It’s not just about the physicians and the coders. So, your practice should consider holding regular training sessions to keep everyone updated with the latest and best practices and to clearly illustrate how documentation affects each person’s role. Regular monitoring and evaluation of the process can lead to improvement over time.

Rely on Physician Engagement

Make sure the person responsible for CDI in your clinic understands the importance of physician involvement. Physicians should be actively engaged in the CDI process, as their documentation plays a crucial role in accurate coding and billing. Regular feedback and communication with them can quickly improve quality.

When communicating, however, “coders and others engaged in CDI should strike a balance of advising, querying, and listening,” says Swartzwelder. “Ask [physicians] about their roadblocks, challenges, and documentation pain points,” he continues. Asking meaningful questions of physicians and listening thoughtfully to their answers helps build relationships and often leads to innovative and efficient solutions.

Effective queries: Training on how and when to query can also help build trust in the relationship. Physicians are busy, so it’s important to only query when it’s necessary. During a past AAPC RISKCON session titled “Establishing an Effective CDI Program,” instructor Amy C. Pritchett, AAPC Fellow, BSHA, CCS, CPC, CPC-I, CANPC, CPMA, CASCC, CDEO, CRC, CMPM, CMRS, CEDC, C-AHI, discussed how to identify whether you need to query the provider. She advises a query when:

• There is a disconnect between physicians and coders.
• Definitions in the CPT^® and ICD-10 guidelines are different from the way physicians learn to document.
• There is no documentation or lack thereof to support the billing and/or claim charges.
• The documentation does not meet medical necessity.
• There are applicable Recovery Audit Contractor (RAC) findings that introduce new questions.
• There are AHA Coding Clinic guidance and quarterly updates that affect documentation requirements.

Audit Regularly

Healthcare is evolving quickly, and providers are constantly getting information from multiple sources, so ongoing documentation reviews are essential to keeping up with all the changes. Conducting frequent audits of the medical records can help identify any shortcomings or errors in documentation. Identifying troublesome patterns early on can also help you address problems before they grow into more serious ones. “I always think of coding documentation reviews as an opportunity assessment. We either have an opportunity to reduce organizational risk, or we have an opportunity to maximize reimbursement for services rendered,” says Swartzwelder.

Collaborate With the Coding Team

The CDI staff should work closely with the coding staff if they are not one and the same. This can ensure the coded data accurately represents the clinical information. This often translates into overall revenue cycle personnel audits. This process involves reviewing the accuracy and completeness of medical coding, billing, and documentation to identify errors or discrepancies that could lead to revenue loss, compliance issues, or operational inefficiencies. This means:

• Reviewing a sample of medical records and associated billing and coding data to ensure accuracy and compliance with coding guidelines and regulations.
• Evaluating the timeliness and accuracy of charge capture and billing processes.
• Assessing the effectiveness of the denial management and appeal processes.
• Checking the accuracy of patient registration and eligibility verification processes.
• Evaluating the staff’s adherence to internal policies and procedures.

Coders are often the people on staff who have their hands directly in not only coding, but claim edits, denials, and general payer policy issues, so making sure internal policies are handled consistently and correctly can be helpful. “For instance, if you have an internal sepsis policy that fills in the gray areas of payer policy, an audit to ensure CDI, coding, edit resolution, and denial resolution staff are all applying that policy consistently is incredibly valuable,” says Swartzwelder.

Use Technology Wisely

Implementing CDI software can help streamline your CDI process. These tools can provide real-time feedback, automate some processes, and help manage and analyze data effectively.

For example, some CDI specialists send the same queries to providers repeatedly to address simple (but necessary) documentation issues. When you can use a technology that “can act as a behind-the-scenes checklist to ensure the basics are met, that’s a huge improvement in efficiency,” says Swartzwelder. More advanced overlays can even help prioritize certain records for human review. “This is a very exciting space right now!” he exclaims.

Stay Centered on Patient Care

Remember that the ultimate goal of CDI should be to improve patient care. The process should aim at accurately reflecting the patient’s clinical status and the care provided to them. Of course, a good CDI process can lead to improved coding accuracy, better patient outcomes, and optimized reimbursement, but “patient care is the only focus every single provider will align with. Anytime we can associate an administrative task/ask with a patient care outcome, we will win,” says Swartzwelder.