Health Information Management

Avoid encoder overreliance

HIM-HIPAA Insider, October 26, 2010

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As hospitals move toward ICD-10, an overreliance on encoders could become more of a problem as coders adapt to the new system, says Glenn Krauss, RHIA, CCS, CCS-P, CPUR, manager of clinical documentation improvement services at YPRO in Corydon, IN. Because of RACs and ICD-10, hospitals need to focus more on documentation improvement and invest in coder education. “RACs are looking at the documentation—they’re not using an encoder to arrive at a code,” he says.

If you think you might be relying a little too heavily on an encoder, consider the following strategies:

  • Take a moment to consider the code the encoder suggests before finalizing a record
  • Research unfamiliar diagnoses to ensure that the code assigned makes sense given the signs, symptoms, and etiology of the condition
  • Use the encoder’s analyzer function, which shows the relative weight, sequencing, DRG, and average length of stay, to ensure that the details correlate with the assigned code

Editor's note: For more tips, view the October issue of Briefings on Coding Compliance Strategies. Subscribers have access to the full article in their newsletter.



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