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Savannah, Ga.-based Memorial University Medical Center (MUMC) had been using an outdated voucher system to record the procedures, services, and supplies provided to emergency department (ED) patients. Charge entries at the 622-bed hospital were based on nursing documentation alone, rather than including physician documentation and orders. This resulted in an incomplete picture of the services performed. In numerous cases, ED documentation did not match charge entries.
An extensive chart assessment identified ED and observation facility coding issues as a primary culprit. In total, MUMC learned it had the potential to improve gross revenue by $24 million per year with more accurate charge capture and coding.
A consultant reviewed a sample of ED and observation charts, including the department’s medical records, chargemaster, and itemized patient statements. The two-day, on-site review process focused on accuracy as well as the quality of the documentation and facility charge capture process. A sample of 64 ED charts and 20 observation charts were reviewed, using patient population totals from the financial analysis provided by MUMC. Patients were assessed using the American College of Emergency Physicians’ ED Facility Level Coding Guidelines.
Snapshot of the results. The assessment concluded that the hospital was under-assigning the patient level of service approximately 75 percent of the time by undervaluing the resources actually used for those patients. The result was very low distribution levels (about 60 percent of patients in facility charge levels 1 and 2) for a Level 1 trauma center with 100,000 ED visits per year. A more accurate distribution would not only improve revenue, but also result in the ability to distinguish patients with relatively high-resource requirements from those with lower resource intensity.
Areas for improvement. The assessment identified the following areas for improvement.
Observation specifics. An analysis of observation patients revealed that clearly documented procedures often were omitted from the bill, amounting to approximately $141 lost in gross revenue per patient. Some charts were missing infusion stop times, which resulted in an inability to bill those services. Of the 20 observation patients who received injection and infusion services, only one patient was billed accurately in accordance with clinician documentation for an overall accuracy rate of 5 percent.
MUMC determined it did not have the staffing or skill sets to make the necessary process changes and opted to bring in a consultant to provide full-service facility coding for its ED and observation services, including facility evaluation and management (E/M) calculation, code assignment, and quality assurance. Using coding software and professional coders, the consultant pinpointed documentation deficiencies and other improvement opportunities.
With the technology-enabled service, billing modifiers could be appropriately assigned, providing additional information about procedures and allowing for more accurate payment. Documentation review and query processes were adjusted to include information recorded by physicians so no procedures were missed.
By the end of the first month, MUMC’s per-visit gross revenue increased to $258 per patient, and by the middle of March the average patient charge reached $1,260, up from the baseline of $1,040.
A few months after transitioning to the new coding and billing services, MUMC’s annualized gross revenue had increased by $24.8 million, the level originally estimated by the assessment, and per-patient charges also had increased to more appropriate levels:
An additional benefit was that the new system and team of coding experts brought the assurance of compliance and data integrity, resulting in accurate, defensible charges for MUMC.
Distribution levels improved to a normal bell curve appropriate for a hospital of MUMC’s size and scope of services, as shown in the exhibit below. Previously undervalued services were remedied by charge capture that more accurately reflected the resources expended by the facility.
As a result, a higher level of service was assigned for about 65 percent of the ED patients, and a lower level of service was assigned to 3 percent. Also, a higher level of service was assigned for about 70 percent of observation cases, where patients routinely require a significant amount of resources.
Coding turnaround times improved to consistent rates of less than 48 hours, well under the contracted time of 72 hours, improving the speed and efficiency of billing. The faster turnaround times led to improved rates of patient payment.
With the support of an outside facility coding service, MUMC had transformed its system of charging and coding while increasing accuracy and efficiency. The technology-based solution enabled the query process between physicians and coders to work, effectively improving documentation overall.
In the end, careful analysis of its coding and billing processes led to improvements in Memorial’s financial health. Improved accuracy and efficiency were the staff’s primary goals, and those were met in the first month of implementation. MUMC’s future plans include consideration of the same services for its labor and delivery department.
Steve Hendrix is a vice president at T-System Inc., Kansas City, Mo.
Elizabeth Morgenroth, CPC, is a medical business analyst at T-System Inc., Kansas City, Mo.
According to the American College of Emergency Physicians, facility coding reflects the volume and intensity of resources utilized by the facility to provide patient care, whereas professional codes are determined based on the complexity and intensity of provider performed work and include the cognitive effort expended by the provider. There are five ED facility charge levels (with five corresponding CPT codes 99281-99285) that differentiate ED care provided by the severity of the patient symptoms and the intensity of resources needed to treat the patient. For example, a patient presenting with an uncomplicated insect bite who only requires a quick assessment would be assigned to a Level 1 facility charge level (CPT 99281). In contrast, a patient with a severe infection who requires constant monitoring and an MRI would fall into Level 5 (CPT 99285). There is also a critical care code, CPT 99291.
Facility E&M (or E/M) codes refer to those for evaluation and management, and are related to reporting care received in nonprocedural encounters—such as instructing a patient how to use crutches, taking a health history, or obtaining a translator for patient communication. Facility procedure codes refer to traditional clinical care.
Source: American College of Emergency Physicians, ED Facility Level Coding Guidelines
Publication Date: Thursday, December 05, 2013
Tom Myers, chief strategy officer, The SSI Group, discusses the shifting payment environment and how it affects providers' patient access and claims management processes.
Jeff Chester, senior vice president and chief revenue officer at Availity, shares his thoughts on "Revenue Cycle 2.0" and how to best meet its challenges.
Mitch Morris, vice chair and global leader, healthcare, Deloitte, and Michael O'Rourke, senior vice president and chief information officer, Catholic Health Initiatives (CHI), share perspectives on the need for transformational IT in health care today.
Brian Kueppers, founder and CEO, Apex, discusses the importance of a robust patient payment strategy in boosting organization revenue and enhancing patient satisfaction.
Brian Grazzini, CFO, HealthPort, describes the importance of efficient and compliant information exchange and audit management in helping HIM staff spend less time on paperwork and more on mission-critical projects.
Cindy Matthews, executive vice president, Community Hospital Corporation, discusses how rural and community hospitals can use collaborative partnering to position for success through tough market conditions.
Rick Heise, senior vice president, revenue cycle, at Cerner Corporation, discusses the importance of integrating clinical and financial data to excel in health care’s changing payment environment.
Russ Graney, founder and CEO for Aidin, and John Laursen, head of business development for Aidin, share insights on how to improve care transitions between acute and post-acute care settings and incentivize high-quality patient outcomes.
Scott Elston, strategic accounts manager, GE Healthcare Services, describes how substantial cost reduction in health care requires rethinking business strategy and asset use.
Robert Williams, MD, director, Deloitte Consulting LLP, and Arielle Freiberger, product strategist, ConvergeHEALTH by Deloitte, explain how sophisticated retrospective, real-time, and predictive data analytics can inform decision making to reduce costs and improve care.
Stuart Hanson, director of business development (healthcare solutions) at Citi Retail Services, discusses how improving the payment experience can benefit consumers and healthcare providers.
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