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ICD-10 requires extensive preparation and training to document to the specificity required.

Under the burden of new regulations and pay-for-performance initiatives to curb costs, hospitals' and healthcare networks' financial systems must find more efficient routes to cut time-to-bill for procedures and diagnostic care. The faster the procedure is coded and billed, the faster the facility is paid. However, despite best efforts, many organizations still struggle to turn around coding and billing in a timely manner. Delays can range from coding to the more severe issue of rejected or denied claims, which prevent payment from occurring in a reasonable timeframe, negatively impacting overall revenues.

Revenue is lost when documentation does not support billing of services performed and can become detrimental to a facility's fiscal success. According to the August 2014 Healthcare Finance article "Focus on Capturing Outpatient Charges", "even some of the most prominent healthcare systems experience significant losses, primarily within outpatient areas of service." Furthermore, "there can be a 20-25% loss in revenue in certain clinical departments."  A large portion of the charge capture loss can be identified in areas of the revenue cycle; however, the majority of lost revenue is attributed to incomplete or inaccurate documentation.     

The problem doesn't stop there. Instead, it proliferates as the transition to ICD-10 draws near. While providers will not be required to use the updated code set until at least Oct. 1, 2015, the reality is that the risk is still the same. With more than eight times the number of codes used in ICD-9, including 72,000 unique procedure codes, ICD-10 requires extensive preparation and training to document to the specificity required. Any gaps or errors along the way will create delays in the coding and billing process and, subsequently, result in lost or delays in revenue.

In an effort to remove unnecessary obstacles in the coding process, many organizations have moved toward same-day billing practices. By utilizing automated procedure documentation and coding solutions that streamline processes, unnecessary middle men are eliminated and accurate and complete documentation is guaranteed so that the claims are accurate at the time of bill drop. As more organizations move toward the structured reporting model, organizations are finding that not only has documentation improved, but the revenue cycle can be condensed from weeks or months to days and even minutes. The issue then shifts from the timeliness of coders and billers to the archaic processes associated with procedure documentation.

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Identifying the Challenges
One problem that carries much of the blame for delays in coding and billing is manual processes such as dictation and transcription. When faced with unclear or illegible dictation and transcription, coders are often left to guess when it comes to coding physician procedure notes, increasing both the incidence of error and the likelihood of rejected or denied claims.

Best practice suggests that all requests be presented to the performing physician for clarification, but that presents its own set of challenges. For instance, it can often take days or even weeks after the procedure has been performed to attain clarification and the likelihood that a physician will accurately remember what took place diminishes as time passes. Adding to the backlog is the time it takes for physicians to respond to such requests, meaning coders must wait additional time before they can successfully code the procedure.

Unfortunately, incomplete and inconsistent documentation can often occur after being handled by numerous people throughout an organization, generating a domino effect that creates delays during any and all of the steps necessary to bill procedures using traditional dictation and transcription processes.

Additionally, appealing denied or rejected claims can add 60 to 90 days to the payment process, even when providers succeed. When the documentation necessary to defend these claims isn't readily available, the audit process can take even longer and the likelihood that the service and/or associated procedures will be ruled as not medically necessary increases - along with the risk for repayment.

Automating the Process: Procedure Documentation and Coding
A number of organizations are implementing structured reporting technology to automate procedure documentation and coding to overcome the challenges associated with manual dictation and transcription processes. These automated processes allow for the improved documentation and streamlined billing and reimbursement. 

SEE ALSO: Revenue Cycle Management

These solutions guide physicians through the documentation processes and remind them to document key elements of procedure to ensure that all information is captured and nothing is missed. Complete procedure notes and appropriate reimbursement codes are then automatically generated - quickly, easily and without dictation.

By efficiently capturing robust details from even the most complex procedures, these solutions reduce the incidence of human error that often occurs with traditional dictation and transcription and, as a result, greatly reduce the incidence that inaccurate or incomplete procedure notes will hold up the coding and billing process. Further, the increased accuracy of procedure documentation ensures that organizations have the information needed to successfully defend denied or rejected claims and protect revenue that might otherwise be lost during the audit process.

Remediation: Same-Day Billing
By implementing solutions such as these, procedures are being billed within just minutes of completion, thus drastically improving the revenue cycle and ensuring that providers are being paid for their services as quickly as possible.

Such was the case for a large not-for-profit medical center in Portsmouth, Ohio. For years, the organization utilized cardiology-specific procedure documentation as part of its full-scale cardiology system. However, while the system supplied cardiologists with a documentation diagram to support procedure documentation, it ultimately created a number of challenges to its process.

For instance, because the diagram did not include the level of detail necessary for certain cardiology procedures, cardiologists were often required to enter a great deal of text in their notes prior to the procedure. In addition, a number of cardiologists still utilized voice dictation for procedures that were not supported by the system such as intra-aortic balloon pumps or pericardiocentesis. As a result, coders often did not have the documentation needed to bill procedures at the appropriate levels and had to go back to the cardiologist for clarification or to capture missing information.

Ultimately, the organization decided to implement a best-of-breed procedure documentation and coding solution to resolve these issues and streamline billing and coding to improve revenue cycle management. Since deployment, they have seen an increase in the quality of documentation as well as a decrease in the turn-around time between documentation and coding, which is now just minutes rather than days or weeks.

In addition, cardiology reports are much cleaner and have all of the important information coders need to get bills out the door in a timely manner and create confidence that what they are billing is accurate.


Revenue Integrity and ICD-10

As hospitals begin to code procedures in ICD-10, challenges to revenue cycle management will only increase as a more specific code set creates more opportunity for error. Subsequently, the likelihood that billing is delayed increases and organizations must wait longer to be paid for services provided. That is why it is imperative that organizations streamline these processes now. By automating procedure documentation and coding, providers will ensure a smooth transition and protect all revenue that is rightfully owed.  

Maria T Bounos, RN, MPM, COC, CSPO is the Practice Lead for Coding and Reimbursement for MediRegs, part of Wolters Kluwer Legal and Regulatory. She can be reached at maria.bounos@wolterskluwer.com

Allison Evans, RHIA, is the Manager of Coding Compliance for ProVation Medical, part of Wolters Kluwer Health. She can be reached at allison.evans@wolterskluwer.com

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