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Emerging Trends: Coding Under PDPM

More than 70% of hospitals outsource at least a portion of coding duties to professional Certified Coders. This fact begs the question: Why shouldn’t skilled nursing operators also seek out the expertise of professional coding experts to optimize coding? After all, accurate, optimal, and timely coding is critical to PDPM success!

According to a recent pilot study by HealthPRO® Heritage and himagine Solutions (one of the nation’s largest coding services), using Certified Coders improved SNF coding accuracy by ~48%. While many providers were hoping to rely on existing facility staff who were coding prior to PDPM, the complexity of proper coding can’t be overstated. In fact, in the short time since the October 1 PDPM transition, HealthPRO® Heritage/himagine Solutions have observed trends in SNF coding practices and identified several areas of opportunity for improvement.

  • Diagnoses should be coded from supportive documentation only from providers (Physicians or Physician extenders if allowed by the state)
  • Coders should be aware specific guidelines exist for “capturing combination codes, and appropriate coding for using terms such as “and” , “with”, “code first”
  • Coding practices related to fractures are very detailed. (e.g.: coders must be comfortable with specific guidelines for use of the 7th character and differentiating coding of fractures vs TJRs.)
  • Complex considerations related to coding dysphagia exist; coders should strictly follow guidelines to make sure coding is captured accurately.

The direction from CMS is very clear: SNF coders must focus on utilizing coding guidelines (rather than perhaps defaulting to established coding patterns, previous assumptions, or coding habits.) After all, coding practices prior to PDPM bore no consequences on reimbursement or compliance, but now there is much at stake! HealthPRO® Heritage predicts SNFs may look to outsource coding services, because optimal coding is THAT important to SNFs’ bottom line. Accurate coding is critical to mitigating possible future risk associated with predicted CMS audit activity since coding is so closely linked to SNF reimbursement.

According to the same pilot study mentioned above, Certified Coders also reduced the time to code new admissions by ~60%. In other words, it may be counterproductive for your staff to invest the time (and training) necessary to review documentation and complete thorough and accurate coding. Consider the opportunity cost associated with relying on Nursing staff since the time spent coding could/should be spent providing direct patient care. The same pilot study mentioned above demonstrated how – by outsourcing coding services – it is projected that Nursing staff would have ~500-600 more hours/year to focus on clinical responsibilities.

Outsourced coding services assure a net positive ROI
HealthPRO® Heritage in partnership with himagine Solutions provides a coding service that offers (much-needed) coding support for dozens of SNFs nationwide who have already enrolled. The feedback so far is overwhelmingly positive:

"I never imagined coding to be as complicated as it is. Our team simply coded just based on our best assumptions. Thanks to this coding service, we don't worry, and we are in a much better place!" 

"We appreciate this coding expertise! Our facility benefits from having an expert to code all our charts, and we also get answers to our questions to help us under the why."

"This coding service has been a huge help to our facility! We now have coding support for all our new admissions as well as our long term charts after the provider visits." 

"Now that himagine is doing our coding, our MDS Director has peace of mind, and Nursing spends more clinical time with residents. It's a win-win!" 

Costs associated with this outsourced coding services are reasonable, and the process is simple: Expert certified coders receive notification of an admission via the EMR &/or email, and examine the hospital documentation, medication list, physicians' notes, etc. himagine Solutions uses an automated coding technology in conjunction with the certified coder’s expertise to assure accuracy and differentiate the nuances and variances of medical information. Codes are entered directly into the SNF's EMR diagnosis list via virtual secured access within 24 hours. The SNF enters the suggested principal, secondary or co-morbid diagnoses into the MDS. himagine Solutions maintains a monthly list of patients’ codes, and HealthPRO® Heritage distributes a monthly invoice to SNFs. Two well-priced, flexible service options are available: Admissions Only ($25/chart) or Full Coding ($65/hour). Please compare this fee with costs associated with having your staff complete coding duties; estimated annual SNF savings overall are predicted to be $9,500-$13,800 (based on 50 charts/month & national average salary).

For more information: info@healthpro-heritage.com

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Tags: Patient-Driven Payment Model, PDPM