I had the opportunity to participate in the RISE Risk Adjustment Academy workshops in Boston on October 21 and 22. Both workshops were great and I found myself taking a lot of notes. As I absorbed the information from the HCC Coding Accuracy program in particular, I realized some insights about HCC coding that were new and exciting to me.
One of the ideas was about the frequent disconnect between physicians and coders. Others brought up this topic before but it received extra attention in our workshop and was clarified for me by Donna Malone, one of our terrific faculty members from the Tufts Health Plan in Boston.
The physician mind is focused on the associated process of evaluating, treating and managing the health conditions presented by each patient. The chart documentation provided by the physician is all framed in the language of diagnostic phrasing and language, and certainly not about codes. A lot of what wording goes into the chart depends on how the physician was trained. When the administrative side of the practice arises, the physician looks to those staff members that he / she has hired to take things from there, whether it be billing, scheduling or whatnot. There is an assumed handoff to others to pick up from where the physician left off and the others began their work.
When the health plan or hired third parties begin hunting down ICD codes, the physician is ill equipped to speak directly to those elements. Instead, it is up to the coders to do the translation work. It is not for the coder to impose or assume ICD codes: those must be garnered from what is reflected in the chart. But if the charting fails to describe fully what is required to substantiate a particular ICD code, it is necessary to work with the physicians to bridge the language gap so that the documentation in the future can be more fulsome and complete.
Herein lies the ticklish problem of physician education. The idea is not to make coders out of physicians. It is to arm them with an understanding of why the diagnostic phrasing needs to be more comprehensive and complete. But why should a physician make the effort to do so? Why not continue on with the current approach to charting?
The education of physicians begins with the idea that the handoff to others downstream has a big impact on those depending on certain kinds of information that only the physician can supply. Secondly, the quality of that information will impact the stakeholders in ways that the physician probably never realized. Ultimately, it will boomerang around and affect the patients and the physicians themselves. It is really up to us to provide the education about those linkages and what to do about them.
In a classic business environment, the process engineers would ask for business requirements to determine what information is needed by the downstream users in order to push back to the original source: in this case, the physician. If the physicians’ perspective is that they are operating in their own practices and the phraseology they choose has a narrow purpose, then they do not realize how useful their documentation is downstream.
The coder’s ability to extract accurate codes is what governs the comprehensiveness of the HCC codes that drive revenues in the case of Medicare Advantage, Accountable Care Organizations, managed Medicaid plans and the new health insurance marketplace. Follow the thread and you end up with at least 85% of the premium dollars spent on health care services for the members. The richer the premiums based upon risk adjustment using the ICD code building blocks, the better the benefit coverage and the lower the premiums for the members. We are talking about the doctors’ patients.
If the correct and complete information is provided upfront by the physicians in the charts, there is less administrative expense to chew away at the health care dollar in the long run. There is less chart pulling and intrusion from the payers and their hired vendors that parachute into the physicians’ practices.
Additionally, if the physicians are working in a risk-sharing model such as an MSSP or Pioneer ACO, or under global or shared risk capitation, then have a stake in the accuracy of the premiums or financial budgets, as well. This is the way in which the financial rewards of operating under these kinds of programs come back to the physicians who are looking to pivot away from volume-based reimbursement and towards a value-based model.
Apart from the financial implications, the powerful tools of population health care management are much less effective if the clinical insights garnered from the ICD codes are compromised by poor or ineffective chart documentation. Valuable programs such as complex care case management, quality improvement, medication therapy management depend on good clinical information, which impact the value of coordinated care plans for health plan members.
In short and simple terms, the physicians no longer operate in a bubble within their office practice space. The interconnectivity requirements of health care today and tomorrow place a high value on getting the clinical insights from the physician expressed in a clear and comprehensive manner so that everyone else in the chain has the benefit of understanding what the physician knows about the patients. In this whole process, the patients will benefit by having better health care coverage and lower out of pocket costs, and the physicians will ultimately receive a share of the financial rewards for providing care in an interdependent environment. This is an essential theme of health care reform.