Understanding the Key Roles for HIM in the Revenue Cycle

1. 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

2. 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.

3. 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

4. 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

5. 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”

6. 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

8. 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!

9. What Elements Impact Clean Claims? • Registration Demographics • The Chargemaster (CDM) • Order Entry/Charge Process • Clinical Documentation • Coding & Classification • Edit & Compliance Process

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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?

17. 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???

18. Uses of Coded Data Quality/Utilization PatientCare Research Education Reimbursement Certificate of Need (Planning) Marketing Budgeting/Resources Historical Documentation Physician Credentialling Contract Negotiation

19. 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)

20. 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

21. 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

22. 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!

23. 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

24. 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

25. 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

26. Accountabilities & Roles for HIM • Code Assignment & Approval • Documentation Requirements • Narrative Description • Revenue Code Assignment • Modifier Application • Corrections • Compliance

27. Patient Billing – Pay Attention to the Impact on HIM Problem Areas: • Claims Scrubbing • Write Offs • Lack of training • Changing codes retrospectively • Late Charges

28. 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

29. 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!

31. 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