Question

Technical Reimbursement Methodologies (Healthcare Management):

Instructions: Real Life Case Scenario

You have been asked to be a member of the Coding Accuracy Subcommittee at your healthcare organization. The primary focus is to improve coding accuracy throughout the organization in hopes of improving future reimbursement. Each answer must be at least 5 sentences long. Each member has been asked to report the following at the next meeting.

a) Investigate and list some known common coding errors.

b) Make recommendations for future continuing education topics for coders to improve coding accuracy.

c) Explain why you think that this could have an impact on the reimbursement cycle.

d) Prepare your report and submit it by the due date and time listed.

Answer 1

Well, i'll try to answer the question in parts for your better understanding.

1. Here are eight of the most common medical coding errors identified by the American Medical Association.
   
   1. Unbundling codes, or using multiple CPT codes for parts of a procedure
   2. Upcoding
   3. Failing to check National Correct Coding Initiative edits when reporting multiple codes
   4. Not appending the appropriate modifiers, or appending inappropriate modifiers
   5. Overusing modifier 22 — increased procedural services
   6. Improper reporting of time-based infusion and hydration codes
   7. Improper reporting of injection codes
   8. Reporting unlisted codes without documentation
   

2. With ever evolving reimbursement models and this fall’s upcoming ICD-10 system code updates, hospitals and medical practices cannot afford the penalties and potential risks associated with inappropriate medical coding. Take the time, energy and resources to ensure accurate coding so your organization is well positioned in the healthcare financial environment now and into the future. Below are some of the strategies that i personally recommend.
   

   1. Invest in Education :

      Medical coding is only as accurate as the knowledge acquired by your coding team. Ongoing education and training is essential for your coding staff because codes are constantly updated, added, deleted, bundled, and unbundled annually. Your coding team needs to stay on top of the latest changes otherwise the potential for a coding error increases.

      Use Detailed Documentation :

      Detailed documentation is the core communication method for your physicians as it relates to patient care. It leads to accurate coding and appropriate reimbursement for your organization. It can help your coding team corroborate medical codes and provide evidence that care was provided. Not only is it important for patient care, but the data collected can be shared with subsequent clinicians. Inadequate or incorrect documentation results in delayed payments and can raise compliance issues. When revisions to codes occur, as they will later this year, providing printed materials can help ensure your physicians know what they need to provide relative to accuracy with documentation. You can distribute templates so they are aware of any new changes and also help them understand any new actions necessary on their part to support accurate coding.

      Perform Regular Audits :

      To ensure better coding accuracy, schedule regular audits to discover if you have any coding issues. This is especially important if changes have occurred to the codes or you have staff turnover. In many hospitals and physician offices, coding is often spread across a large, diverse group of personnel. This can sometimes lead to inconsistencies. Regularly-scheduled audits can identify areas where additional training or support may be necessary.

      Provide Up-to-Date Coding Resources :

      Organizations should have the most current references related to medical codes at their fingertips. It should be accessible online as well in print. Archive the older annual published references in case a coding issue arises from a previously coded chart. In addition, CMS issues quarterly updates on modified codes so be sure to subscribe to these updates so you always have the latest medical codes.

      As a busy healthcare executive, we understand keeping up with annual medical coding changes can be overwhelming at times and may even be costly as it relates to training and education. But it is necessary to ensure that you can provide accurate coding at all times. If you’re too busy to manage your coding efforts or do not have the financial means to be on top of the latest changes, consider adding outside audit services and outsourcing your coding practices to a coding expert such as Ovation Revenue Cycle Services.
      

3. If you could assign a noise level to each area of your revenue cycle, in what decibel range would medical coding fall? Often overlooked and sometimes not even recognized as part of the process, coding is usually “quiet” — when it’s done right and there is a solid strategy in place, that is.

   However, with continuous regulatory changes and staffing pressures — and sometimes a lack of top-down focus — coding can begin to look like a cluttered desk. At first you don’t notice the extra papers, but as they accumulate into stacks and your visible surface space disappears, the time-consuming task of dealing with the backlog and finding a workable solution going forward is simply overwhelming.

   That’s why leaders who are looking to optimize performance and maximize efficiency overall should never turn a blind eye to coding.

   Medical Coding is Vital to Your Revenue Cycle :

   Coding lives mid-cycle, pretty much smack-dab between scheduling and receipt of payment for the care rendered. It’s not patient-facing, and it’s not particularly glamorous (that is, unless you hire rock star coders). But, accurate coding leads to a clean claim, which results in prompt reimbursement, and that’s why coding impacts your bottom line profoundly.
   
   It’s quizzical, then, that some healthcare organizations throughout the nation — even the prestigious ones — don’t think of coding as part of revenue cycle operations. Often coding answers to an HIM or compliance director rather than to a financial leader, which only perpetuates the communication gap and lack of collaboration between coding and billing.

   To understand why coding and billing need to learn to speak the same language, consider preventive versus diagnostic care. Under the Affordable Care Act, insurance plans cover preventive care without patient cost sharing (that is, without co-pays, coinsurance, or deductibles), but services that are not classified as preventive care are subject to cost sharing. It is important for physicians and their coding and billing staff to differentiate between the two — and to catch each other’s errors — in order to avoid blindsiding patients and avoid experiencing a revenue loss. When coding is revered as part of your revenue cycle, efficiency and communication improve, and that’s a sure win.

   Medical Coding May be Slowing Down Your Process :

   Bottlenecks can occur anywhere in your revenue cycle, and coding is no exception. Your volume of charts to code might be large and ominous. You might be understaffed. Your coder productivity may suffer as the result of inefficient workflows.

   When the pace of coding slows, revenue cycle performance is impacted :

   If you have a backlog of charts to code, you risk missing the timely filing deadlines set by payers. The issue here is almost always under staffing in the coding department. Coders today come at a premium price, and hiring, training and retaining the good ones have associated costs, too.

   Most information systems allow customizable edits to stop claims with errors from going out the door. They can drive automation with solutions like coding crosswalks for specific payer requirements. But sometimes, a crosswalk is mapped to the wrong code, resulting in denials. It takes an eagle-eyed coder to discover errors of this nature so that they can be corrected within the system. Straight up, not every coding department takes time, or enough time, for system edits.

   Working denials is a time-consuming, multi-step process that includes determining the reason, researching, re-coding, and re-submitting, all under yet another deadline. And honestly, few coders love to work denials, especially when they are already busy with new charges, which always hold the priority. Further, many coding operations are so focused on “working” denials that they miss opportunities to prevent them by identifying trends and putting in place proper solutions. Are new system edits required? Is there a coder-education opportunity to prevent repeat errors?

   Big-picture thinking about how to prevent errors is a must, and it goes way beyond just correcting and re-submitting them.

   The Bottom Line :

   Coding might not be the first thing that comes to mind when you have problems in your revenue cycle, but we assure you, after partnering with dozens of healthcare organizations of every size and shape across the nation, that having competent, efficient coders whose work blends seamlessly into the revenue cycle will result in fewer denials and quicker, more accurate adjudication.

   In this way, coding can stay “quiet” for the right reasons, and you’ll avoid that unnecessary clutter on your revenue cycle desk.

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