Quality versus quantity…a real dilemma

Happy New Year to all! As we make (and break) many New Year’s resolutions this month, I’d like to talk about resolutions for quality.

I appreciate the challenges and pressures to get claims coded and out the door and meet productivity standards. I am sure many organizations think I live in an ivory tower and not in the real world. Let me just tell you that we all have some sort of productivity standards in our jobs for which we are held accountable (myself included). Finding the right balance means hitting the mark on productivity while still doing a quality job.

They just don’t get it: Who is to blame for increased complication rates?

Let me start by saying Happy Holidays to everyone. However, I am feeling a bit like Mr. Scrooge. I have heard from many clients lately regarding their struggles with obtaining accurate complications rates. In almost every instance, there is finger-pointing (with coding and CDI taking the hit) and even software gets blamed for the increased capture of complications rates.

So let me explain a few things:

HIMagine That! ICD-10 fallout?

Donna: Hey, Sue! We haven’t talked since AHIMA. Did you get back in time for ICD-10 go-live?

Sue: Yes, I was in my office, bright and early on October 1. I couldn’t wait to see how it was going to go!

Donna: Well, I talked to a lot of people at AHIMA and it was clear the general mood was one of excitement. Finally, we’re able to move forward with ICD-10 after all these years of preparing and practicing.

Sue: I heard pretty much the same thing. One HIM director captured it perfectly when she said, “Bring it on!” I think everyone was confident, anxious to get going and ready to deal with the fallout, if any.

You are ready

No more kicking this ICD-10 can down the road. It’s finally here.  We have all been waiting, planning, preparing, training, and yes, worrying. With ICD-10 only 24 hours away, will it be gloom and doom as some suggest? Will the sky really fall when ICD-10 becomes effective? How could it when there have been so many years of effort and dedication by so many from across the healthcare industry?

Present and Accounted For…Potentially Preventable Complications

We all know the phrase “First do no harm,” a philosophy that is a driving force in health care. In other words, if we do not do anything to improve the health of our patients during their stay, at least let’s not allow anything bad to happen to them on our watch.

HIMagine That! Codes and Kangaroos Down Under

Donna: Hello from Down Under where they have been using ICD-10 since 1999!

Sue: Hi! How has your work and your visit been going? Have you learned any ICD-10 tips worth sharing?

It’s Complicated! Just Because You “Can” Doesn’t Mean That You “Should”

Remember as a child using the argument, “Everyone else’s parents are letting them” and your mother asking, “If everyone else jumped off a bridge, would you jump too?” When it comes to capture of diagnoses, the same type of argument can occur between HIM and Quality. Coding professionals will refer to the alphabetical/tabular indexes, official Coding Guidelines and AHA Coding Clinics for ICD-9-CM to support the capture of a diagnosis or for specific code assignment.  Quality staff will refer to the clinical picture, the probable intended meaning of the author and in applicable cases, the CDC diagnostic criteria as support for not assigning a code. I can remember a very passionate “discussion” between myself and a coding professional about a complication and whether or not it had to be assigned as a complication.  I stated, “Just because you can code it that way does not mean you have to code it that way!”

HIMagine That! Inter-Rater Reliability

Donna: Sue, have you heard people using the buzz word inter-rater reliability in the context of ICD-10?

Sue: Isn’t that a statistical formula used to determine agreement or consensus between two raters or judges?

Donna: Yes, but HIM professionals are using the term, not the formula, to compare the agreement rate between two or more coders coding a case in ICD-10.

AHIMACon vs. Comic-Con: We All Have a Role to Play

Last week I checked in on Facebook from the AHIMA convention in San Diego. My brother, who attends San Diego Comic-Con religiously every year, decided to weigh in:

Brother: My San Diego convention is superior to your San Diego convention.

Me: My convention is more conventional than your convention.

Brother: I expect you’ll have better Cosplay, though.

Me: Lots of Clark Kent and Lois Lane types.

It turns out this exchange fit perfectly with the vibe at #AHIMACon14 over the following three days. I arrived at the Monday general session in time to see and hear several inspirational messages about how innovation and, as AHIMA CEO Lynne Thomas Gordon put it, “embracing reinvention,” are the keys to success in health information management.

Getting their Money’s Worth…Value-Based Purchasing

Value-based purchasing further emphasizes the ripple effect and spider web of CDI, HIM and Quality. Everyone “knows” about value-based purchasing, but what is it comprised of?

Value-based purchasing (VBP) is both a broad and narrow quality measurement tool. Broadly defined, pay for performance (P4P)/ VBP is payer-developed metrics to measure value compared to reimbursement given. Two examples are accountable care organizations (ACOs) and bundled payments. A narrow definition is a program mandated by the Affordable Care Act of 2010 and administered by CMS. VBP has been in development for almost 10 years but was formally introduced for FY 2013. Through the Medicare program, incentive payments are made to hospitals based on either how well they perform or improve against their own baseline on each domain comprising VBP. There are four domains: clinical process of care, patient experience of care, outcome (FY 2014 forward) and efficiency (FY 2015 forward). Each domain is assigned an associated weight. For example, in FY 2015 clinical process is 20 percent of the total VBP score, patient experience is 30 percent, outcome is weighted at 30 percent and efficiency rounds it out at 20 percent.