New encoder technology coupled with CAC drops weekly DNFB, improves accuracy

Heather Eminger CCA, AHIMA Approved ICD-10 Trainer, Product Manager Dolbey

About Methodist Healthcare

• Six-hospital system with 1,725 licensed beds, based in Memphis, Tennessee
• Nationally ranked in seven specialties
• 65,000 IP admissions, 326,000 OP visits, 6,000 births, 40,000 surgical procedures annually
• Corporate coding department—37.5 remote FTEs perform coding for all six hospitals
• Implemented Dolbey Fusion CAC with integrated TruCode Encoder in November 2015

Challenges

• ICD-10 implementation October 2015
• Previous encoder contract expiring
• Coders navigating five separate systems to code cases
• Medical necessity edits (LCDs and NCDs) verified using paper “cheat sheets”
• Coding productivity reports created manually
• Frequent coder overtime to meet weekly billing goals

Results

• Coders navigate two systems versus five
• All productivity reports available electronically
• LCDs and NCDs automatically verified
• Improved coding accuracy
• Enhanced identification of patient safety indicators
• Billing goals easily surpassed each week without overtime

New encoder needed and CAC on the wish list

Donna Hunt, RHIA, AHIMA-Approved ICD-10 Trainer, Corporate Coding Director at Methodist Healthcare, spent several years researching encoder and Computer Assisted Coding (CAC) solutions. With her legacy encoder contract due to expire, Hunt had been looking at TruCode for a while and liked all the features. While also considering CAC vendors, she hoped to find a solution that worked hand in hand with TruCode.

The goal was to identify an integrated encoder-CAC solution to streamline the coding process and address the organization’s long-standing coder productivity challenges. Hospital administration was supportive of this endeavor. According to Hunt, “They agreed there would be a great return on investment—fewer coders, better quality, and improved productivity.”

CAC evaluation begins

Hunt began the process of choosing a CAC solution by determining three criteria for the ideal CAC vendor with the following:

• a solid partnership with an encoder vendor;
• demonstrated ability to improve quality and productivity; and
• a comprehensive reporting system enabling end users to monitor productivity.

Following demonstrations from several CAC vendors over a two- to three-year period, Hunt and her team chose Dolbey Fusion CAC with the integrated TruCode Encoder, because they felt it would provide a streamlined and standardized process to enable coders to be more productive and accurate. The team felt that having the TruCode Encoder embedded in the product would enable coders to easily access coding references from within the CAC solution.

Implementation concerns and resolutions

The Methodist team voiced the following concerns related to implementation of the new CAC system:

• Change of encoder product. The implementation of the new encoder was exciting and frightening at the same time. Coders had become dependent on the logic-based encoder they had used for years, and were concerned about switching to TruCode’s knowledge-based encoder. To offset fear, Hunt focused coders on ICD-10 book learning to reinforce ICD-10 coding guidelines and practices. This facilitated a smooth transition to TruCode, enabling coders to take advantage of all coding references that are integrated within the TruCode encoder.
• ICD-10 go-live looming: Methodist began the CAC build process in April 2015. Because the current encoder contract was ending, the goal was to implement Dolbey Fusion CAC prior to ICD-10 go-live on October 1, 2015. However, due to ICD-10 transition-related concerns, the project was postponed to November 2015.
• How to adapt to CAC: Early on, it was difficult for Methodist staff to imagine how the CAC solution would fit with their facility. To assist with that issue, Dolbey sent a representative onsite to observe current processes and help staff understand the required process changes. This allowed the Methodist staff to envision how the CAC would be used within the organization, and guide the system build to match their requirements.

CAC system build

The planning phase for the Dolbey Fusion CAC build and implementation kicked off in April 2015. The implementation team included members from Dolbey, TruCode, and Methodist—IT, HIM management, coding staff, and leads. After Dolbey’s initial site visit to observe current processes, all work was conducted via weekly conference calls.

Methodist wanted to fast-track the implementation to ensure completion prior to the impending ICD-10 transition. Dolbey recommended slowing the build to properly meet system requirements. While Hunt’s team first resisted this advice, they eventually agreed that go-live prior to October 1, 2015 was not a realistic goal.

Slowing the build process allowed Dolbey to fully customize the system to accommodate Methodist’s needs. Hunt also secured a short contract extension with the current encoder vendor. The CAC go-live was rescheduled for the week before Thanksgiving 2015, six weeks after the conversion to ICD-10.

Concurrent training and go-live

All coders received onsite training the morning of go-live. The four-hour sessions included training on the Dolbey Fusion CAC solution and the TruCode encoder. Inpatient and outpatient coders were separated into customized sessions based on the specific chart types for which they were responsible. Each coder coded a few charts at the end of their formal training session, so any questions regarding the new process could be addressed. In the weeks that followed, both Dolbey and TruCode closely supported the coders to ensure they mastered the nuances of the new solution.

Following training, Methodist “flipped the switch,” allowing coders to begin working on the new system. Immediately after go-live, a few minor issues required easy resolution: Proper display of documents in the CAC system, adjustment of coding queues, and identification of certain types of accounts that could be auto-closed.

One year later—coding department light years ahead

As of January 2017, the Methodist coding department has been completely transformed. Coding remains current without contract coders or overtime. The organization’s coders no longer work late on Friday afternoon to ensure that weekly goals are met. And Hunt’s goal of less than $1.2 million outstanding in DNFB at the end of the week is consistently surpassed. The current average is less than $200,000 each week, and has dipped as low as $35,000 in DNFB.

For Hunt, the most important benefit of the combined Dolbey and TruCode solution is improved coding productivity. The automated productivity reports allow Hunt to see the entire coding process and quickly identify any workflow gaps. These reports have shown productivity consistently higher than minimum requirements as follows:

• inpatient records—three records per hour (required two per hour);
• outpatient, same day surgery, and observation records—seven records per hour (required
• 6 per hour); and other records (ancillary, recurrent, ED)—average up to 30 per hour (required 20 per hour).

The quality of coding has increased from 88% prior to go-live to 95% today, an overall 8% increase. “We can identify more potential Patient Safety Indicators as the CAC picks up any indicators coders might have missed,” says Hunt.

The road ahead—next steps for CAC at Methodist

Hunt’s plans to expand the use of CAC technology within the organization include the following:

• develop new reports enabling the coding department to track uncoded records due to missing documentation;
• incorporate the use of CAC within the clinical documentation improvement team workflow; and
• continue to add new chart types for CAC auto-closure, further streamlining coder productivity.

“Computer assisted coding technology opens dozens of new doors for organizational workflow improvements,” concludes Hunt. “Once implemented, your opportunities are endless.”

Hunt’s seven tips for a successful CAC implementation

1. Prepare slowly. Ideally, allow yourself one year from contract to implementation. Have a good understanding of the timeframes required for each phase.
2. Engage IT. Your organization’s IT department must understand the time requirements for full CAC implementation. Involve IT during initial planning calls with your vendor and schedule ongoing conversations with them throughout the process.
3. Determine how the CAC will improve productivity and ensure it works to meet your needs.
4. Identify all coding reports you are currently using so you can replicate them in the CAC.
5. Manage staff expectations and fears. Jobs are not going away—they are changing from assigner to reviewer of codes.
6. Plan for a huge learning curve in the beginning and budget for training—before, during, and after.
7. Hold onsite meetings with your vendor rather than conference calls—they assist the understanding of best practices and allow the facility to make the best choices.