Compliance Pain Points: Balancing Revenue Protection and Risk Mitigation

By Nancy Hirschl, BS, CCS, AHIMA-Approved ICD-10 Trainer
Vice President, HIM Services, Streamline Health, Inc.

No matter the size of your organization, compliance is complicated. At times, it can seem like a balancing act between managing risk and protecting revenue. Lean too far in one direction and the organization could be in jeopardy – go too far the other way and risk losing out on thousands of dollars in revenue. Especially in the mid-revenue-cycle, the accuracy of reported diagnosis and procedure codes is what holds these two concepts in balance. This is an important notion to understand, because if the chief compliance officer can trust the accuracy of the coders, risk is lowered and revenue has a greater potential to increase.

For many organizations however, putting that much faith in the accuracy of coding operations seems like a pipe dream. While many coders are extremely talented, with high-level problem solving skills, there’s still room for human error. Read on to take a deeper look into the pain points coders face, how they affect the mid-revenue cycle, and what can be done to solve them:

Coding pain points
To understand where problems can arise during the coding process, it helps to understand exactly where the mid-revenue cycle begins. While the entire concept might seem highly technical nowadays, it still begins in a relatively old-fashioned manner: with pen to paper.

The mid-revenue cycle is initiated at the point of care when the caregiver begins documenting the encounter, capturing the patient’s condition and supporting details, as well as the subsequent diagnosis, recommended therapies, actions, etc. It continues up to the point where the coding function is complete and the case is submitted to the business office for billing.

Because the mid-cycle begins with a natural language input — either in writing or type — there is an immediate margin for error. When the description of the patient’s condition reaches a coder, they have to make a critical decision: which ICD-10 code correctly describes the patient’s condition? A slight inaccuracy at this stage could mean leaving money on the table. A major error could mean having to reimburse a payer down the road, after that money was already counted as revenue. But this is far from the only risk to the mid-cycle.

One way that organizations have sought to reduce human error is via computer-assisted coding. The computer reads the natural language input and suggests an ICD-10 code. This process often alleviates one complicated piece of the problem, but in reality it sometimes leads to further confusion. For instance, the computer may misread the original input from the physician and suggest a code that doesn’t accurately reflect the patient’s experience. A veteran coder will spot this error immediately and make the necessary correction, whereas a new coder may not realize the mistake and bill according to the computer’s suggestion. If this situation happens too many times, veteran coders may dismiss the computer’s help altogether, which creates its own risk. It all amounts to less margin for error and a greater potential for either lost revenue (undercoding) or exposure to audits and clawbacks (overcoding).

Code auditing pain points
Since there are always a few unavoidable issues with coding, organizations perform regular pre- and post-billing audits to determine how much risk is associated with the mid-revenue cycle. Audits help managers determine who the most skilled coders are, and who may need additional training and feedback. However, auditing often isn’t a perfect system either. Many organizations still use manual spreadsheets to track and report data. This system is flawed in many ways – again, the margin for human error is high, it’s incredibly time consuming, it’s expensive, it still may not catch everything, and it doesn’t easily lend itself to efficient reporting. This is a huge headache for compliance officers, because it can make their job all the more difficult.

Coders and code auditors each have operational challenges, but overcoming them is easier said than done. That’s why Streamline Health has introduced two targeted solutions to help organizations lower financial and legal risk, optimize revenue, and maintain compliance.

Streamline Health’s revolutionary solutions
Because there are multiple risks to an organization’s mid-cycle-revenue, Streamline Health has developed two digital solutions that reduce human error and bring code auditing into the 21st century.

The first solution is the CORE platform, an auditing workflow and reporting engine that replaces manual spreadsheets and gives individuals within the organization the ability to instantly generate and share valuable data across departments. With this solution, organizations can easily organize complicated or even multiple audits. CORE gives organizations the freedom to conduct coding audits quickly, efficiently and at a high volume, which simply isn’t possible using manual solutions.

The second solution is Looking Glass® eValuator™, a form of artificial intelligence-assisted auditing that has the capability to improve an organization’s mid-cycle results from the ground up. Using an algorithm based on hundreds of empirical rules, eValuator can flag coded encounters in real time, giving fully compliant suggestions on how the coding might be modified to optimize data quality and reimbursement. This tool vastly improves the moment-by-moment process of coding by empowering coders with actionable feedback on their efforts—including narrative feedback on the suggested changes. Almost everyone with a smartphone has a digital assistant in their pockets at all times – why shouldn’t coders have a digital assistant to give them a helping hand? The tool even shows real-money values of code changes as well as a percent chance of accuracy. Compliance officers can set the boundaries of these metrics so that anything over a certain percentage is automatically flagged for a second look. Additional alerts allow compliance offers to be proactive, like automatically flagging all coding from a new medical/surgical program, or that from a coder-in-training. And as an automated solution, eValuator can be leveraged against ALL charts, not just a select sampling, which supports large-scale improvements to coding accuracy and revenue integrity.

Risk mitigation and revenue optimization will always be a balancing act. But why tip-toe on a high-wire when you could be closer to safety? CORE and eValuator are the solutions you need to bring achieve revenue integrity harmony.