The Executive Suite: Improving medical coding processes to achieve value-based care success

Friday, October 16, 2020

Improving medical coding processes to achieve value-based care success

Primary care physicians (PCPs) face increasing challenges in the current healthcare environment: not having enough resources to care for patients, declining practice revenues, and overwhelming administrative burdens. On top of all that, there is a necessary, but mounting pressure to shift to value-based care. Having run a cardiothoracic surgery practice for 25 years, I have found that an overlooked solution to these challenges and a path to value-based care is improved documentation and coding.

Value-based care is about efficiently providing the most cost-effective, yet highest quality care that improves patient outcomes. There are a number of studies showing that physicians in value-based care programs demonstrate higher quality of care than physicians only in fee-for-service models. These improved outcomes in value-based care are dependent on PCPs being at the center of patient care.

In this transition to value-based care, documentation and accurate coding are critical for PCPs. Value-based care programs depend on PCPs—who have a thorough knowledge of the patient—accurately assessing, and documenting, the needs of their patient population, reflected by disease acuity or health risk. A thorough and accurate assessment ensures that provider reimbursement will be sufficient to cover the costs of care coordination and additional services necessary to achieve improved patient outcomes and better quality of care.

Unfortunately, many PCPs, especially smaller practices or solo practitioners, lack the technology, care coordination expertise, staff, time, and other resources to improve their documentation, coding, and quality initiatives—all of which are necessary to thrive in value-based care. To consistently deliver accurate coding, quality of care, and succeed in a value-based care model, PCP’s need to be empowered with tools and resources to efficiently and accurately document, code diagnoses, and manage patient care to achieve improved outcomes.

It all starts with data and technology. PCPs must be able to ingest and synthesize patient data from disparate sources to create actionable care insights. With a comprehensive view of the patient with the aid of technology, providers can accurately capture and document all active medical conditions for their patient population with the appropriate documentation for clinical validation. The providers can also identify and close quality and clinical gaps in care and increase the utilization of preventive services. The result is better patient outcomes and better performance in value-based care.

But, technology alone does not solve every problem, especially when it comes to improving coding and quality of care. PCP practices, particularly those who serve seniors, have endured some serious challenges during the COVID-19 pandemic in providing preventive services and difficulty engaging patients, which have hindered coding and quality initiatives. I am optimistic about PCP-centric solutions to these problems, that combine both technology and administrative support to relieve PCPs of the extra administrative burdens and empower them to deliver care and thrive in value-based programs.

For years, I’ve heard providers say, “When value-based care comes, then I will pay attention to coding and risk adjustment.” But, then it’s too late. Each year, alternative payment models shift more risk to providers. Plus, the CMS data collection lags considerably, meaning allocated resources for patient care in future years are dependent on the coding and documentation being completed by the provider today. The time for PCPs to focus on improving documentation, coding, and value-based care initiatives is now.

Moving forward, primary care physicians have the opportunity to prioritize documentation and accurate diagnosis coding to get the resources to succeed in a new value-based care environment.