Training Plan for Physicians and Coders

1 Training Plan for Physicians and Coders Background The CMS is the organization that oversees various programs, including Medicare, Medicaid, state and federal health insurance marketplaces, and the children's health insurance programs (USA.gov, 2021). This organization releases a Medicare provider review analysis file containing inpatient information at the hospitals level (USA.gov, 2021). The revenue cycle department analyzes this file and compares the information provided with other organizations offering similar services. The revenue cycle department provides feedback to the hospital administration concerning the areas that need rectification.

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2 Recently, while comparing the hospital's MedPAR data with other organizations in the market, the revenue cycle department realized that the hospital's patient population for surgical spine encounters is focused on lower-paying, less severe diagnostic related groups. An independent auditor reviewed over 100 surgical spine charts and discovered problems with physician documentation and comorbidity and complication coding. Below are training plans for codes and physicians to ensure that identified problems do not occur in the future.

Training Plan for Coders Problem Identification Coders are responsible for reviewing medical documentation and translating medical notes into codes (Buck & Grass, 2015). These codes pass essential messages to insurance companies, medical providers, and other payers. Proper coding failure passes inaccurate messages to t parties involved. In this case, coders were not capturing correct details concerning patient comorbidities and complications. The auditor revealed that the coding staff failed to account for a huge proportion of the patient comorbidities and complications in the process.

Impact of the problem on the organization The failure to account for patient’s comorbidities and complications has significant implications for the organization’s revenue. It introduces coding bias as various comorbidities and complications are missed, leading to a lower-level DRG assignment.

Recommendations for improvement Coding errors are common causes of claim denials. Therefore, coders should review claim denials to identify why some services were not reimbursed (Elsevier, 2018). Coders should conduct a comprehensive evaluation of medical documentation to ensure all comorbidities and

3 complications are capture and accurately coded. Coders should consult the physician for all documents that are not clear.

Recommended training mechanisms Instructor-led training is the best training delivery mechanism for coders in the hospital.

This mechanism is beneficial since it increases the coders' overall understanding of the topic.

This strategy is effective when providing a large target group with a relatively small amount of information within a short period. It allows interaction between the instructor and the coders, ensuring the learners receive instant responses.

Training Plan for Physicians Problem identification In physician documentation, the auditors noted that these professionals did not provide sufficient details and key indicators to enable the coding staff to code the records at a higher level. Information in the records indicates that records for most patients, whose acuity level was much higher, were coded at lower levels.

Impact of the problem on the organization Improper physician documentation can negatively affect hospital revenues. Poor documentation leads to some medical information being left out during coding leading to partial Medicare reimbursement for the services offered (Buck & Grass, 2015). It also contributes to inaccurate statistical databases, revenue loss, and poor patient care outcomes.

Recommendations for improvement Physicians should only utilize approved medical abbreviations during documentation.

These professionals should also stick to their scope of practice to ensure they only document

4 properly trained subjects (Buck & Grass, 2015). Double-checking of documentation is also recommended to ensure errors are identified and rectified.

Recommended training mechanisms On-the-job training is the best intervention to improve physician’s knowledge of various coding issues. In this training method, physicians are allowed to witness how coders perform their job. Physicians witness how missing data and inaccurate information affect coding. It helps physicians understand the importance of medical documentation on coding, reimbursement, and revenue growth.

5 References Buck, C. J., & Grass, J. L. (2015). Step-by-step medical coding. Elsevier Health Sciences, Elsevier (2018). Buck's step-by-step medical coding, 2019 edition e-book. Elsevier Health Sciences, 2018 USA.gov (2021). Centers for Medicare and Medicaid services. https://www.usa.gov/federalagencies/centers-for-medicare-and-medicaid-services