Risk Assessment Calcs Now Available

Hierarchical Condition Categories (HCCs) are a hot topic when discussing risk assessment and payment for the long term care of our 65 and older patient base. Medicare Advantage enrollees are provided ongoing care reimbursement based on a specific set of demographics and diagnosis code data submitted to the payer over the course of time.

As auditors we find ourselves facing the challenge of educating our Providers on the importance of documentation that is both accurate and complete in order to produce the proper risk assessment. If a patient has multiple chronic conditions, it’s critical that all underlying health problems are reported annually to provide an overall view of the patient’s care situation.

To help you navigate the often confusing risk assessment process, Swiftaudit now includes an easy to use HCC lookup as well as a basic ICD-10 risk score calculator.

Preliminary risk scores can be accessed directly from the list of CPT related diagnosis codes in each Encounter.

Or you can view HCCs and calculate risk scores from the Coding Tools option in the upper navigation.

Our HCC lookup screen will display the appropriate category cross reference to your diagnosis codes, as well as the risk factor associated with each.

As always, we’ll continue to keep an eye on current audit trends and needs in order to provide the best possible tool set for our auditors and the clients they service!

For more information on how risk assessment and scoring works, check out Dr. Tom’s blog post on Calculating RAF Scores.

Our Toolset Is Getting Even Better!

Swiftaudit now gives you access to RVU and Physician Fee Schedule information with a quick click. You can access the RVU/PFS screens through the main navigation, or from the Actions dropdown menu in your Encounter Header.

Select your Medicare Locality and click Calculate.

We’ll fill your screen with useful data, including:

  • Geographic Price Index
  • RVU and calculated Physician Fee Schedules
  • LCDs
  • Payment Indicators
  • More…

Click on the displayed LCD and we’ll show you all the appropriate HCPCS codes that apply. Click on More Info for any LCD and we’ll zing you over to the official CMS site for comprehensive details!

And the best news is, we won’t charge a single penny more for this fabulous new feature! Our goal is to provide auditors with a powerful toolset to make your job easier – we want to make you look good.

If you haven’t tried Swiftaudit yet, visit us at Try It Free and take advantage of our absolutely free, no credit card required 30-day trial. Come see what you’re missing!

National Coding Contest Raises Serious Industry Questions

By Holly Louie, RN, BSN, CHBME
Original story posted on ICD10monitor: May 20, 2019

Contest indicates coding accuracy is below expectations.

Central Learning is a web-based coding assessment and education application. Since 2016, the company has conducted an annual national coding contest to measure ICD-10 coding accuracy and production. The initial premise was to evaluate how coding accuracy and production work, compared to ICD-9. The oft-stated common industry accuracy benchmark under ICD-9 was 95 percent. The findings of the 2018 contest indicate that the industry at large still lags far below past expectations. In addition, as production under ICD-10 increases, accuracy decreases.

The 2018 contest included contestants from 47 states, and 4,471 real medical records were coded. Sixty-one percent of the contestants held the American Health Information Management Association (AHIMA) coding certification, and 26 percent held AAPC coding certification. Contestants self-designated their area of coding expertise. The overall coding accuracy for 2018 was 57.5 percent.

Not unexpectedly, years of experience is a key determinant of accurate coding. Coding accuracy was grouped by experience categories of less than five years, 5-10 years, 10-20 years, 20-30 years, and more than 30 years. For inpatient coders, greater than 30 years of experience scored 77 percent, while less than five years of experience scored 48.5 percent. Outpatient coders scored 10-15 percent lower for each category. 

For inpatients, the average primary diagnosis accuracy was 67.8 percent; secondary diagnosis accuracy was 38.8 percent, and CPT assignment accuracy was 35.9 percent. Overall DRG accuracy was 72 percent. Common errors were lack of specificity, failure to specify laterality, acuity issues, and site designation.

Another surprising finding was that although there have been annual fluctuations, an overall significant improvement in ICD-10 coding accuracy has not occurred. Inpatient coding accuracy for 2016, 2017, and 2018 has been 55, 61, and 57.5 percent, respectively. Outpatient ICD-10 accuracy for the same years has been 38, 41, and 42.5 percent.

One possible explanation was provided by AHIMA. Unlike historical coding, whereby the coders utilized the books to find codes and read the applicable rules, today’s automated coding assistance tools present codes or code choice based on standardized algorithms or word identification. Those designated codes are not necessarily correct; they are simply possible choices to consider. Likewise, electronic health record (EHR) coding is typically far less than optimal, and often inaccurate. These tools do not replace coder knowledge, understanding of the applicable rules, or interpretation of the authoritative guidelines. If coders rely upon automated coding options or designations without critique and analysis, errors will be prevalent.

I believe that the surprising findings present concerns regarding compliance, many state and federal initiatives, and payment issues. For inpatients, incorrect primary and secondary diagnoses, incorrect acuity, failure to report complications, accurate conditions present on admission, etc. all directly impact reimbursement. For outpatient claims, it is common for payors to deny for reasons including unspecified diagnoses, lack of laterality indication, and failure to adhere to the authoritative coding guidelines. Emergency department coding scored very low accuracy. It is highly probable this could contribute to surprise medical bills. Other considerations are all of the Centers for Medicare & Medicaid Services (CMS) quality payment initiatives. Coding accuracy is critical to avoid penalties and for correct bonuses. 

In addition, the increasing focus on social determinants of health is dependent on accurate reporting of patient circumstances and risks that impact care and patient compliance. As both federal and commercial payment models move to new methodologies, diagnosis coding is becoming the driver of all reimbursements.

Immense amounts of time and dedicated work have been invested in clinical documentation improvement. That begs the question of why that has not resulted in the expected improved coding accuracy, as reflected in the 2018 coding contest. 

I believe the coding accuracy findings offer a huge window of opportunity for the industry. Detailed analysis to compare the findings to the metrics of your organization is recommended. New and less experienced coders need much more scrutiny than your veteran coders. Final code selection compared to coding assistance tool choices is also strongly recommended. Auditing production benchmarks weighing accuracy is prudent.

It may be easy to say that the results of this contest do not represent your business or enterprise. However, the scope, depth, and breadth of three years of contest findings says to me that they probably do.

Getting Started Guide

Welcome to Swiftaudit! Click on the “expand screen” icon in the lower right corner of the graphic above to open the full screen tutorial in a new tab. We’ll show you how to get up and running quickly with our easy to use audit functions and menu system. Let the auditing begin!

Custom Exams

In our ongoing effort to provide auditing flexibility, we now offer the option for you to create your own custom exam checklist for any CPT category!

To begin, choose Custom Exams from the main navigation dropdown.

Each custom exam is given a name of your choosing. Gender and age requirements can also be specified.

Define up to (6) levels of custom CPT calculation by building a checklist of
optional and mandatory items you must see in the documentation to qualify for that code.

Within the Encounter, choose the desired custom exam and Swiftaudit will determine the proper code based on your responses.

You can define as many custom exams as you’d like, and Swiftaudit allows you to Upload/Download your exam definitions to share with others. Let your CPT reviewing begin!

How Does Your Physician Compare?

We know that educating your client on how to code accurately is a top priority, and we’re ready to help! Swiftaudit uses the National Provider Identifier (NPI) database to access coding data from the most recent Public Use Files (PUF) and compare your physician’s annual coding results with both local and national numbers.

From either the Provider list or the Provider detail screen you can select a graph that focuses on New or Established patients. With one click you can see how your physician measures up compared to others in the same specialty, the same zip code, or across the nation.

Use your mouse to hover over the graph and view distinct data point details for specific E&M codes. Or right-click to print your graph for a later presentation. Easy!