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Understanding the Key Roles for HIM in the Revenue Cycle. Presented at PHIMA 2011 by: Darice Grzybowski, MA, RHIA, FAHIMA President, HIMentors, LLC. Objective: This lecture discusses the touch points between HIM departments and the Revenue Cycle including: Patient Access
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Understanding the Key Roles for HIM in the Revenue Cycle Presented at PHIMA 2011 by: Darice Grzybowski, MA, RHIA, FAHIMA President, HIMentors, LLC PHIMA Annual Meeting
Objective: This lecture discusses the touch points between HIM departments and the Revenue Cycle including: • Patient Access • Charge Description Master • Patient Care Process • Billing/Editing/Remittance/Denials and • Decision Support • as well as the important role that HIM professionals take in insuring data integrity.
Background of Speaker • 30 years experience in HIM administration, teaching, and consulting • Founder of HIMentors, LLC in 2005 – consulting company specializing in HIM operational improvement and EHR implementation • University of Illinois graduate, RHIA, , Master’s in Clinical Data Management • AHIMA Fellow • National speaker, author and Triumph award winner
Outline • Understanding Reimbursement and the Revenue Cycle • What Makes Up a Clean Claim • Understanding the Chargemaster & Coding Impact • Key Problem Areas in the Revenue Cycle • Getting Paid and Getting Audited • Hot Topics & Roles • Conclusion & Q & A
Defining the Revenue Cycle • Basic Issues for CEOs and CFOs are shared • Quality Care / Accuracy of Financials & Data • Getting Paid • Compliance with Federal Regulations • Understanding the process from scheduling through patient care, health information management processes, and billing/collections to final data analysis = the “revenue cycle”
Getting Paid? • Charitable Foundations (generally community based) • Bonds (ratings and financed loans) • Third Party Payers (Insurers) • Federally Funded (Medicare, Medicaid (states), etc.) • Commercially Insured (i.e. BCBS, Aetna, Cigna, etc.) • Managed Care (HMO, PPO) • Worker’s Compensation/Disability • What Happens When you Don’t Get Paid: • Charitable Care, Write Offs, Bad Debt
What is a Clean Claim? • Clean Claim: Definition can vary… • Are all the required fields completed on a claim? • All the fields that should be completed, are filled in adequately enough to pass billing edits/rejections only? • All the fields that should be completed are filled in with accurate/appropriate information = Clinically Clean Claim!
What Elements Impact Clean Claims? • Registration Demographics • The Chargemaster (CDM) • Order Entry/Charge Process • Clinical Documentation • Coding & Classification • Edit & Compliance Process
Sample UB04 6 HIPAA Electronic Transactions - 837X Data Flow 4 24-30 14 15 42 43 46 47 44 45 4 Bill Type 6 From and Through Dates 14 Date of Birth 15 Sex 24-30 Condition Codes 42 Revenue Code 43 Revenue Code Description 44 HCPCS/CPT Code 45 Date of Service 46 Number of Units 47 Line Item Charge 67-75 Diagnosis Codes 67-75
Revenue Cycle Stakeholders? -Coding -Compliance -Decision Support Information Technology Board Patients & Public Senior Management Ancillary Department managers Clinicians Financial HIM RCM Team -Pricing -Contracting -Billing -Supply chain
HIM in the Revenue Cycle -- Other Data Integrity Issues? Pricing & Performance Improvement Decision Support Billing & Remittance Mgmt. DNFB HIM Coding -- Grouping --Statistics -- ROI Patient Care / Order Entry Clinical Documentation Patient Registration Medical Necessity – Admit Diagnosis – Present on Admission Flag - Duplicate MRNs Physician Practice
Registration Process • Typical problem areas include: • Medical Necessity/ABN issues • Duplicate Medical Record Numbers • Master Patient Index integrity problems • Lack of skilled personnel • Lack of adequate admitting diagnoses/symptoms and other information • Present on Admission • Errors in Patient Type
Order Entry/Charge Process • Inconsistent or inaccurate procedures can cause as much havoc as an inaccurate chargemaster • Single source of authority • ‘Common’ language for clinicians • Preparation for downtime order and charge collection • What is accountability value compared to patient care? • Modifiers? • Daily charge/order reconciliation reports
Documentation • Documentation is the missing link! • “If it’s not documented it wasn’t done, and if it wasn’t done, it shouldn’t be documented!” • IMPORTANCE of current, concise, complete documentation
HIM coding • Outpatient day surgery • Outpatient ambulatory procedures (minor non-operating room procedures) • GI Laboratory (endoscopies) • Coded based on physician dictation • Accounts with charges attached to Revenue codes 360-369, 490-499, 750-759 –HIM?
Understanding Hard v. Soft Coding • Hard Coding: Chargemaster or Structured Text or NLP – Natural Language Processing, and Charge Sheets/Superbills • For Inpatient AND Outpatients: CPT/HCPCS Procedures are used • Soft Coding: Documentation Translation: • For Inpatients: ICD-9 Diagnoses & Procedures • For Outpatients: ICD-9 Diagnoses & Procedures and CPT • Procedures • Future: (WHO) ICD-10, ICD-10 PCS, SNOMED, MS-DRGs, APR-DRGs (severity/risk), Computer Assisted Coding???
Uses of Coded Data Quality/Utilization PatientCare Research Education Reimbursement Certificate of Need (Planning) Marketing Budgeting/Resources Historical Documentation Physician Credentialling Contract Negotiation
Coding & Reimbursement • CPT vs. ICD • Epidemiological purpose vs. Reimbursement purpose • Introduction of Compliance/Anti-Fraud activities (OIG & RAC) • Influence of fiscal intermediary policies • Medical Necessity impact • Other changing rules (i.e. patient status)
Impact and History of PPS Inpt. Acute Outpt. Acute Inpt. Rehab Inpt. LTAC Home Health SNF Physician Inpt. Psych. RUGS 1990 (?future) RBRVS APC-2000 CMG-2001 2005 Ref.DRG 2002 HHRG 2000 DRG-1982 (APR-DRG) 1993 CRG (episodic) Type of Grouper that applies to the Prospective Payment System DRG APR-DRG E&M Fee Sched. PAI issues & OP Rehab CMG Inpatient Psych DRG Long Term Acute Care DRG OASIS document. MDS document Part A/B
Challenges to Coding Integrity • Different people – different skills and knowledge • Long Training Time • Understanding Source Documentation • Lack of audit & reconciliation (forms and content pre coding) • Late charges/Late documentation • Competing ‘edit’ systems • Discrepant software updates
Example of single year CPT Coding Changes: • 458 CPT code changes in 2006 • 277 Newly added CPT Codes • 71 Revised codes • 110 Deleted CPT codes • 225 Changes to guidelines and related notes. • 250,000 CCI code pairs to check for edits!
Parts of the Chargemaster CPT Revenue Codes Charge Protocol/Units of Service Clinical Knowledge Pricing Rates CDM Cost Report Knowledge Billing Knowledge The Correct Procedure? The Full Extent of the Procedure? All the Procedures? Supply & Pharmacy Mgmt. Reimbursement – PPS & Fee Schedules Service Item & GL Dept. Claim
CODING PROCESS CARE DELIVERY FINANCIAL PROCESS Charge Capture Billing HIM Physician order Dx & Procedure CPT Code Rev.Code Price CDM Table ICD-9 Diagnosis & Procedure Codes CPT Codes Scheduling & Registration Care delivery & charge capture $ Order entry system UB Claim Payments Financial Reports
Challenges in CDM Management -Standardization (corporate vs. individual facilities) -System Interface Compatibility -Dedicated/Qualified staff! -Emergence of New Procedures -Local payer rule variation -Annual Code Updates
Accountabilities & Roles for HIM • Code Assignment & Approval • Documentation Requirements • Narrative Description • Revenue Code Assignment • Modifier Application • Corrections • Compliance
Patient Billing – Pay Attention to the Impact on HIM Problem Areas: • Claims Scrubbing • Write Offs • Lack of training • Changing codes retrospectively • Late Charges
After You’ve Billed • Denials management (or PREVENTION) • Remittance reconciliation: Expected vs Actual payment- both Inpt and Outpt • Analyzing the data • Making Improvements in your process • Educating others
AUDIT REVIEW DOCUMENTATION (SWAT) TEAM: • Pre-Payment Review • Post-Payment Review • Random Review • Focused Review • HIM Department • Business Office • Compliance Officer • Information Services • Other Clinical/Ancillary • Every…order=result=code=bill=collect!
THANK YOU! Any Questions? One Westbrook Corporate Center Tower One, Suite 300 Westchester, Illinois 60154 708-352-3507 www.himentors.com Email: info@himentors.com *Note: All content in presentation confidential & proprietary to HIMentors,LLC & Client 31