The Executive Suite: Caring must be prioritized over coding

Unlike traditional Medicare fee-for-service plans, Medicare Advantage (MA) programs receive a capitated monthly payment for an individual beneficiary’s cost of care that is partially based on a risk score, which increases or decreases depending on an enrollee’s health compared to a national average.

Health plans offer greater financial incentives to providers for more thorough documentation and coding of beneficiaries’ diagnoses. In other words, higher risk scores translate to higher payments. Naturally this leads to instances of payers gaming the system with so-called “upcoding” or “uncorrected coding intensity.”

The practice has become so widespread that CMS currently applies a 5.9% reduction to MA risk scores to counter the effect. Now, the Medicare Payment Advisory Commission (MedPAC), which advises Congress on Medicare payment issues and is currently focused on improving the accuracy of MA risk adjustment, is pushing to rein in excess payments to MA plans.

The practice has not gone unnoticed by the Department of Justice, which is taking action against MA plans that artificially inflate MA payments. In 2020, the commission found MA risk scores were about 9.5% higher than those for comparable beneficiaries in traditional Medicare because of coding intensity.

It’s all about the codes…Or is It?

Today there is ample advice and guidance in the industry counseling providers and health plans on how to best optimize risk-adjusted coding to qualify for higher risk scores.

Unfortunately, all too often the one consideration that is omitted from these conversations is the basic fact that this is not a matter of simply picking a code and being done with it. The supporting clinical documentation not only must reflect the selected diagnosis, but it must also show that the condition was appropriately assessed and treated. The inclusion of more specific or additional codes alone will not be sufficient when the auditors arrive.

All this emphasis on “optimized” coding raises a very fundamental question about providers’ (and payers’) primary focus: Is the coding taking priority over the caring? At face value, the question may sound absurd, but the escalating attention paid to the coding makes it a valid consideration.

The role of legacy technology

Now consider the role of the electronic health record (EHR) in this situation. After all, the EHR is the first destination for all these codes and should help guide clinical actions. At the point of care, the EHR is supposed to serve as a tool to help the clinician assess and document the patient’s conditions and the prescribed treatment. But all too often, they must spend an inordinate amount of time searching through volumes of disjointed data to get what they need. With so much disorganized information, is it any wonder that clinicians struggle to find relevant history about their patients’ existing or suspected problems?

So, when you think about it, the EHR is little more than an inert code repository primarily employed to justify diagnoses and billing––rather than to empower clinicians to improve patient care. We’ve been mistakenly focused on the codes and coding for too long. What good is getting the code right, managing codes, managing lists of codes, or managing the updates of codes, if we’re not leveraging the technology we already have to improve patient outcomes?

The focus should be on using these tools to help the clinician manage the patient.

It is ridiculous to accept the thought of the EHR as a clinically inert obligation, but that pretty much sums up its current value. Consider the alternative––converting EHRs into diagnostically interactive tools that clinicians use to get instant access to all the clinical information related to a patient’s problem. And what if those same tools could also help satisfy the quality measures and documentation requirements with customized workflows? Suddenly, clinicians would be more empowered to improve care.

This is important because it’s not about the coding. It’s about the caring.

With the growth of MA and other risk-based incentive programs, and the increased focus on pay-for-performance and quality, providers are increasingly charged with moving the needle on patient care. Having the right code might help with getting paid, but it won’t move the care needle.

As value-based care models continue to gain acceptance, clinicians will increasingly need access to diagnostically-focused views for each patient––including each of their medical issues. They shouldn’t be required to randomly search through disparate sections of clinically inert EHRs to find the information they need.

We need to emphasize care over coding, and by transforming EHRs from static code repositories to diagnostically interactive tools to help coordinate care. Optimizing EHRs in this way will do more than just satisfy regulatory requirements and ensure proper compensation; it will also empower clinicians to deliver optimal care.