By Karen Youmans, MPA, RHIA, CCS, and Vanessa Youmans, MA, RHIA, CCS, CPC
As healthcare organizations strive for continuous efficiency and sustainability, mergers and acquisitions (M&A)among diverse medical facilities provides organizations new opportunities to reduce costs and generate a larger footprint in both current and new markets. The trend of consolidation between healthcare systems and physician practices is continuing at a rapid pace. According to recent data compiled by Avalere Health and the Physicians Advocacy Institute (PAI), hospitals acquired 8,000 medical practices from July 2016 to January 2018 while 14,000 physicians left private practice to enter into employment agreements with hospitals during that time.
As this trend continues, health information management (HIM) departments continue to acquire new coding professionals and additional coding responsibilities. However, some healthcare systems may lack resources to take over additional workloads that result from an acquisition. Such a transition may necessitate professional pro-fee coding, which is significantly different than facility coding. In addition, it is important to implement a coding quality improvement plan for the pro-fee side of newly acquired responsibilities as a result of M&A activities.
The coding quality improvement plan consists of five main pillars:
- Quality audits
- Coder mentoring
- Coding support
- Coding education programs
- Coding policies and guidelines standardization
Once an acquisition has occurred, it is vital to conduct an initial and subsequent periodic quality audits for coding accuracy. While each organization conducts quality audits in different intervals, it is recommended that the coding professionals’ accuracy information be captured, measured, and analyzed as soon as possible after the acquisition and then on a quarterly basis. Documentation must be reviewed to ensure adequate support for the reported ICD-10-CM diagnosis codes and CPT procedure codes. Detailed reports need to be provided with individual encounters per coder or provider as well as accuracy rates. These reports should include any recommended code changes for coder, provider, and supervisor vetting. Meetings with the physician group managers to discuss trends for action plans, including potential physician education regarding documentation, additional tools needed for coding professional support, transition of products for edits, coding policy documentation, and more are essential to this process. It is important to note that the pro-fee coders may never have experienced a coding audit, so taking the time to explain the entire plan to them is essential to success.
If any of the coding professionals do not meet the 95 percent accuracy rate on the quality audit, then progressing quickly to the coding professional mentoring program is a valuable piece of a coding quality improvement plan. The main objective is to perform concurrent secondary reviews to enhance the physician group pro-fee coders’ knowledge, according to pre-approved criteria, in order to correctly code/bill the encounter. This process also will identify cases that need further training, education, one-on-one coaching, additional tools, and support from coding professionals. Pro-fee coders may not have been provided with constructive feedback in the past, so providing them some mentoring time will be essential to the success of both the pro-fee coder and the merged healthcare system. In addition, training on various coding tools (e.g., encoders, NCCI manual, NCCI edits, coding references, etc.) may be needed.
The coding support pillar of a coding quality improvement plan should include a question queue serving physician group pro-fee coders for questions that may arise during their day-to-day operations. Results from coding support can be gathered and implemented in tailored education programs and one-on-one coaching meetings for the physician group pro-fee coders. More complex providers or specialty groups may need to be transitioned to a more experienced pro-fee coder until a transition plan can be developed to bring that complex specialty coding back to a physician group pro-fee coder. This transition plan can include additional education and training for the selected pro-fee coders. Coding support may also include ongoing dialogue discussions with physicians and surgeons. This should encompass coding management involvement to answer any questions from physicians and pro-fee coders. Conference calls may need to be scheduled for continual physician and coding professional feedback.
Coding Education Programs
The fourth pillar is implementing a coding education program. Many of the pro-fee coders may not have had the previous opportunity to be cross-trained in various specialties. They may not have any formal training in the specialty they currently code. In addition, provider specialty-specific coding educational programs may need to be developed. The educational program takes the physician group pro-fee coders through a re-review of medical terminology, anatomy and physiology, ICD-10-CM diagnoses, and CPT procedural coding for each specialty (e.g., orthopedics, neurosurgery, cardiovascular, general surgery, etc.). A comprehensive education program should include lectures, conference calls, webinars, homework assignments, periodic review of ICD-10-CM and CPT coding guidelines, example exercise completion, online quizzes, comprehension testing, and a final exam.
Coding Policies and Guidelines Standardization
It is not uncommon to find that there are very few, if any, written coding policies for acquired physician groups or that the coding policies differ from specialty to specialty. When a healthcare system acquires new pro-fee coders and additional coding responsibilities, coding managers should begin to gather any and all formal and informal written coding policies and guidelines. Within the coding quality improvement plan, it is imperative to standardize the coding policies and to align them with all official coding guidelines and your internal healthcare system compliant coding guidelines and policies. For example, for pro-fee coding, is it appropriate to code diagnoses from the admitting history and physical performed the day before the actual surgery? Or are the diagnoses codes for the pro-fee surgery only to be taken from the operative report and pathology report? A standardization of the coding policies and guidelines will be crucial for both the pro-fee coder and the auditors. One important tool resulting from a coding quality improvement plan could be the implementation of a pro-fee coding handbook. A transition plan can be created by the coding management team with the objective of presenting a documented structure for the physician group pro-fee coders to benefit from a successful knowledge transfer and more consistent coding practices, while maintaining high coding accuracy rates.
Addressing Unique Challenges
M&A activity in physician groups will continue to increase. This can expand a provider's footprint in the market. Identifying the new, unique challenges that result from all this change, and then tailoring steps to address them, is imperative to the quality of medical coding and its impact on a healthcare facility’s bottom line.
The best approach to addressing these challenges involves assessing and developing a plan with a holistic approach that positively impacts coding quality on an enterprise level. This approach requires an objective team with high accuracy rates and a high level of expertise in the pro-fee coding, and proven experience in coder mentoring and education. A few recommendations and considerations on the practical side are also important:
- Recognize the differences between facility CPT coding versus pro-fee CPT coding
- Acknowledge the importance of interaction between coders and providers
- Assess pro-fee coders’ experience and expertise
- Provide education to providers and coders
- Standardize guidelines and procedures
- Measure performance for continuous improvement
Physicians Advocacy Institute. “Updated Physician Practice Acquisition Study: National and Regional Changes in Physician Employment 2012-2018.” February 2019. http://www.physiciansadvocacyinstitute.org/Portals/0/assets/docs/021919-Avalere-PAI-Physician-Employment-Trends-Study-2018-Update.pdf?ver=2019-02-19-162735-117.
Karen Youmans (firstname.lastname@example.org) is president/CEO, and Vanessa Youmans (email@example.com) is director OP/ProFee coding and auditing division of YES HIM Consulting, Inc.
"Coding Quality Improvement Plan Implementation for Hospital-Acquired Physician Groups"
Journal of AHIMA