Accuracy and efficiency of coding and documentation are crucial for successful revenue cycle management (RCM) and to ensure optimal reimbursement. Applying technology to mid-cycle RCM operations enhances the quality of clinical documentation improvement (CDI) and coding processes. This article explores the tools and strategies that are reshaping the way healthcare organizations enhance documentation quality, streamline coding workflows, and maximize revenue capture.
Technology in Clinical Documentation Improvement
Worklist Prioritization
Effective worklist prioritization strategies are necessary to maximize the efficiency and impact of CDI efforts. Traditionally, a discrepancy in the number of CDI specialists compared to the overall patient population has led to the adoption of a sampling approach to documentation, where only a subset of patient records is reviewed. This method, however, results in a considerable number of missed opportunities for queries, as a large percentage of patient charts go unreviewed. The reliance on manual processes and the lack of technological support exacerbate the issue.
CDI Technology can pre-screen the entire patient population using natural language processing (NLP), knowledge graphs, and other artificial intelligence (AI) models and identify potential query opportunities. The CDI specialists can then get a prioritized worklist which has charts that have a high probability of potential queries.
Automated coding systems with AI and NLP can identify patterns and trends that may indicate coding errors, while knowledge graphs can provide the right explanations and recommendations for subject matter experts to validate. Once identified, the prioritized charts are distributed to CDI specialists in a focused approach that helps maximize the efficiency and impact of the CDI process.
Collaboration between CDI professionals and medical coders is essential for maintaining the financial well-being of healthcare organizations as they have distinct but complementary roles in managing patient records. CDI specialists ensure the clinical accuracy and completeness of patient documentation to identify areas for clinical improvement. Medical coders, on the other hand, focus on assigning the appropriate codes with precision to optimize reimbursement and reduce denials.
Utilizing a single platform for medical documentation and coding offers a multitude of benefits, including a holistic chart review that combines clinical insights with coding perspectives. This integrated approach ensures accurate and compliant documentation and correct capture of the principal diagnosis, complication or comorbidity (CC/MCC), length of stay (LOS), and severity of illness/risk of mortality (SOI/ROM). As a result, healthcare providers can expect improved reimbursement rates and reduced claim denials. Additionally, this streamlined process leads to fewer coding queries and duplicate queries, thereby enhancing physician engagement and overall efficiency in the medical documentation process.
Queries and Physician Engagement
As the primary creators of medical documentation, physicians play a pivotal role in enhancing documentation quality. Their engagement and active participation in responding to queries are critical for the success of any CDI initiative. Challenges can arise in ensuring active physician participation in responding to queries. Implementing CDI technology can help standardize the querying process, establish specific service level agreements (SLAs) for query creation and responses, and simplify the mechanism for physician engagement. This technological intervention not only facilitates easier responses to queries by physicians but also allows for the analysis of response times and the integration of responses into patient documentation. Such data can be invaluable in fostering productive interactions with physicians, ultimately leading to educational opportunities that further emphasize the significance of their role in CDI.
Key Performance Metrics
Metrics play a crucial role in the context of discussions with physicians and the integration with other departments, such as utilization management, case management, and discharge planning teams. Using technology to track key performance indicators (KPIs) such as CDI querying, physician response time, case mix index (CMI), LOS variance, and more is instrumental in both improving performance in managing length of stay and discharge planning as well as monitoring overall success.
Technology in Coding and Auditing
Technology has also made audits easier and more efficient . Instead of manual audits, technology can identify potential compliance issues and audit trails. This not only saves time and effort but also ensures compliance with regulatory requirements.
Worklist Prioritization
Worklist prioritization has been significantly enhanced through the integration of robotic process automation (RPA) to leverage bots to perform repetitive tasks. This allows for the efficient download of inventory data directly from client systems. Utilizing customer-defined priorities, inventory is then accurately uploaded into the workflow system to ensure seamless task assignment and adherence to prioritization without manual intervention. Stringent rules within the workflow ensure that tasks are addressed in their assigned order to ensure compliance and efficiency. This automation and workflow optimization eliminates issues with worklist prioritization, significantly improving operational efficiency.
Smart Sampling
Smart sampling is revolutionizing the approach to quality management in inpatient coding by leveraging advanced analytics to enhance accuracy and efficiently identify and correct errors before billing. Error patterns and identifying key factors that influence the precision of inpatient charts, such as the complexity of diagnosis-related group (DRG) codes and the length of patient stay, are analyzed. The resulting algorithm is integrated into workflow tools to allow charts with a high propensity for errors to be flagged. In one example, the auditing process reviews 15% of charts on a pre-bill basis and then focuses on high-risk charts. This targeted approach not only ensures that only corrected charts are billed, thus boosting the accuracy of billed charts, but also significantly improves the error identification rate by 50%. This methodical strategy has led to a notable improvement in coding quality, achieving a quality rate of over 95%.
Appeal Packet Creation
Creating an appeal packet for appealing a denial through RPA involves several steps to streamline the process and ensure accuracy and efficiency. Bots can create appeal packets by segregating the explanation of benefits, medical records, and coding letters with rationale on appeal. Once the appeal packet is finalized and verified, RPA can automate the submission process by electronically transmitting the packet to the appropriate recipient, whether it's the insurance company, regulatory agency, or other relevant party. This ensures timely submission and reduces the risk of human error. By leveraging RPA in the creation of appeal packets, organizations can streamline the appeals process, reduce manual effort, improve accuracy and compliance, and ultimately increase the likelihood of successful appeals.
Accurate Procedure Coding
RPA can play a crucial role in preventing procedure coding errors through intelligent keyword recognition. Once keywords are identified, RPA bots can cross-reference them with established medical coding standards, such as the Current Procedural Terminology (CPT) or International Classification of Diseases (ICD) code sets. RPA bots are equipped with error-detection capabilities to flag inconsistencies or discrepancies in procedure coding. If the identified keywords do not align with the expected codes or if there are conflicting details within the documentation, the bots can raise alerts for further review by coding professionals. Overall, by leveraging intelligent keyword recognition, RPA can significantly reduce the risk of procedure coding errors in healthcare settings, leading to improved accuracy, compliance, and quality of patient care.
Technology has transformed mid-cycle revenue operations, particularly in the automation and streamlining of CDI programs and coding processes. From worklist prioritization to coding and audits, technology improved the efficiency and accuracy of medical coding and documentation. Contact us for assistance in strategically applying technology to mid-cycle operations in your organization to enhance your revenue cycle management and maximize your reimbursement potential.
Suhas Nair
