The Pareto principle, also known as the 80/20 rule, or ‘the law of the vital few,' states that for many events, roughly 80% of the effects come from 20% of the causes. This principle was named after an Italian economist, Vilfredo Pareto, who developed it after observing the peapods in his garden. Pareto noticed that 20% of the peapods contained about 80% of the peas. The 80/20 rule applies to just about anything, like what technology can do versus what you need actual human people to do for coding or document improvement initiatives in your physician group.
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80%: How will coding technology work in your practice?
As the focus of healthcare changes, or even as medical coding moved from ICD-9 to ICD-10, the technology has been adapted to meet these new challenges. If your organization invests in CAC solutions you must be knowledgeable about the limits and capabilities of the CAC functions and even then it must be properly integrated into your EMR.
CAC Technology Solutions: Computer assisted coding (CAC) technology has many benefits that can improve medical coding workflows and increase accuracy. However, CAC fits the 80/20 rule. CAC solutions require careful planning and preparation to implement and even then, you can’t predict exactly how well it works from go live. There may be unforeseen mapping issues or build issues that would cause a number of claims to hit edits. For example, if the technology component was not mapped correctly, it may not “see” that a drug code was billed with an administration code, and would stop the charge from going to the payer. In cases like this, where the CAC isn’t fully functioning from the go-live, you must have a contingency plan in place to catch the claims that the technology doesn’t.
HCC Technology Solutions: The recent focus on HCC coding (Hierarchal Condition Categories) is another good example of how technology must be adapted to fit the current need.
The good news is technology exists to help prompt your providers to accurately document medical records with the comprehensiveness and degree of specificity needed to assign the proper HCC codes. This helps more accurately depict the overall health of your patient population, which in turn impacts reimbursements in some risk based arrangements.
In fact, there are a few different technology offerings that may make things easier:
Some EMRs offer inherent solutions to assist with HCC coding. Additionally, The Advisory Board Company offers a bolt-on technology which attaches to the EMR and to remind the provider during patient care encounter in real time. This technology highlights what needs to be documented for HCC coding to accurately represent the patient’s risk and the whole cost of care.
A second type of technology solution fits into the equation post-EMR but pre-claim. It sits between the EMR and practice management system and makes suggestions about what could be done to amend the provider’s note to properly support the ICD-10 codes that map to the HCC codes. This solution, pioneered by RCX Rules supports the theory that some providers may be inclined to ignore the pop-up reminders and document as they are used to. Both of these technology solutions will help your providers document their notes accurately and thoroughly, but what about implementing it? Because it’s new technology, there may be bugs or missing pieces.
20%: You still need people
While referencing the ways in which technology can streamline processes and generally make things easier, it’s worth noting that the robots aren’t taking over just yet. Your organization still needs certified medical coders on hand to act as stop gaps when the technology doesn’t quite fit the bill. People are the contingency plan that play an important role in overcoming technology implementation roadblocks and beyond.
What about the truly complicated medical records that the technology can’t reconcile?
It might not make sense to use the EMR technology solutions for certain segments of your patient population or even for certain specialty areas. A coder can “see” the issues presented with new technology and manually check each claim and correct the ones that the technology doesn’t work for prior to being sent out to a payer. Because when technology works and works well, it will make things easier, but improperly wired technology can cause massive issues that are much harder to correct if the problem isn’t caught by a person and resolved.
The Bottom Line
Technology solutions are developed and implemented to help improve efficiency and streamline process flows. With HCC coding, it may not make sense to “turn on” the technology in some cases as it’s not going to be a “one solution fits all” process. You will always need educated medical coders to look at the record and analyze the data for thoroughness and accuracy.
Similarly with CAC, after go live, there may be an increased need for certified coders to help with a higher number of edits until all of the issues are resolved. As your practice dives deeper into HCC coding and CAC technology, remember to think about the whole picture and the Pareto principle.