Complex Cases in ICD-10: Why Flexibility and Critical Thinking Skills Matter

Complex inpatient encounters often involve new, experimental surgical procedures. Most common in academic medical centers, these cases create hurdles for coders and coding management. Managers may need to forego the push for productivity while coding professionals take time to conduct research, ask questions and assign the correct codes.

When it comes to complex cases, flexibility and critical thinking skills are required to ensure correct reimbursement capture and mitigate the risk of denied claims.

Critical Thinking in Clinical Coding

Encouraging coding professionals to engage their critical thinking skills when coding complex cases or new, experimental procedures is paramount. Here are three ways to begin:

  • Help coders understand the entire coding picture through critical thinking combined with knowledge of anatomy, physiology and pharmacology.
  • Encourage an investigator mentality and thinking outside the box when performing research to ensure coding accuracy.
  • Build knowledge and consistency among team members—share research required to code complex cases.

In the January 2018 issue of the Journal of AHIMA, I will provide five strategies to help HIM leaders build a critical thinking mindset across coding teams.

Impact on Productivity

Taking the time to conduct research, ask questions, and code complex cases right the first time versus repeating efforts when a claim is denied or rejected by the payer is always preferred. However, coding managers must allow flexibility in their productivity expectations.

When coders spend time to research cutting-edge medicine, productivity may be slowed in order to ensure correct reimbursement and avoid claims denials. A proven strategy is to flex productivity benchmarks for complex cases. Consider the following tactics:

  • Use length of stay (LOS) as basis for adjusting productivity goals on complex cases.
  • Look at total charges for new, highly complex surgical procedures when lower LOS occurs.
  • Consider using a combination of LOS and total charges to adjust coding productivity standards.

A critical thinking mindset, coupled with flexibility in productivity expectations, promotes collaboration as coding professionals and managers tackle new challenges and learn new skills to advance the coding profession.

Please let us know what types of complex cases your coding team faces, and what strategies you employ to support a critical thinking mindset.

Sarah Humbert

RHIA, ICD-10 AHIMA Certified Trainer, Coding and Compliance Manager