Coding Connections In Revenue Cycle Management

Coding Connections in Revenue Cycle Management

Recently, there has been significant discussion in the healthcare industry about improving the revenue cycle, primarily focusing on enhancing the bottom line through more effective and efficient processes. For hospitals to maintain financial viability under current healthcare pressures, the revenue cycle must be a focal point, with Health Information Management (HIM) and coding professionals playing crucial roles. This article explores the vital connections between coding and various revenue cycle components, including patient access, HIM, and patient financial services.

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The integrity of the revenue cycle begins at patient intake, where accurate collection of data such as patient demographics, insurance information, and the reason for admission is essential. The Medical Record Number (MRN) serves as a fundamental link that connects documentation to the services provided. An incorrect MRN can result in incomplete or inaccurate coding, which may compromise the accuracy of billing and clinical records. Consequently, collaboration between HIM and patient access staff to ensure proper MRN assignment is critical.

Patient type assignment, distinguishing between inpatient versus observation, is typically designated during patient registration. When patient type is incorrectly assigned, it can lead to delays in billing and potential denials, as post-service corrections are resource-intensive and slow down revenue flow. Therefore, front-line staff and coding professionals should work together to correct and clarify patient type early in the process.

Additionally, documentation during scheduling and registration, especially regarding test orders and reasons for procedures, is crucial. Providing source documentation ensures that coding professionals have complete information to assign accurate codes. Educating front-line personnel on test order requirements and ensuring access to source documentation facilitates precise coding, ultimately impacting reimbursement and compliance. Linking coding professionals to these front-line activities helps in adhering to medical necessity requirements, thereby reducing claim denials.

In the realm of documentation, HIM, coding, and chargemaster services, clarity on who assigns codes and where they originate is essential. Certain services, especially routine diagnostic tests like laboratory and radiology, are often hard-coded into the chargemaster because their codes are consistent. Conversely, surgical procedures are usually assigned by coders based on source documentation. Determining which codes should be hard-coded versus coder-assigned ensures consistency, reduces conflicts, and minimizes billing errors.

The accuracy of coding also hinges on thorough source documentation. Coders rely on clinical notes to validate the codes they assign. When documentation is incomplete or vague, it can lead to incorrect billing, compliance issues, and potential audits. Implementing concurrent documentation management programs and queries to physicians during patient care improves the quality and completeness of documentation, ensuring proper reflection of the clinical picture.

Establishing coding quality and productivity standards is vital for compliance, efficiency, and revenue enhancement. These standards support the timely and accurate coding of services. Regular internal and external audits help sustain high-quality coding practices, ensuring that coding adheres to current regulations and guidelines. Continuous education allows coders to stay current with evolving coding rules, reducing errors and denials.

Revenue integrity teams play a crucial role in reviewing charges, documentation, and coding to identify lost revenue opportunities and prevent billing issues. Such teams often include coding professionals who provide expertise in resolving discrepancies and suggesting improvements.

Within patient financial services, the processes of billing and denial management are interconnected with coding. Data from patient access, chargemaster, and coding culminate in generating bills. Advanced edit systems apply Medicare-specific edits, outpatient and inpatient edits, and coding initiative checks before claims submission. Resolving issues flagged by these edits requires knowledgeable personnel to minimize delays and denials.

A key tool in this process is the Discharged Not Final Billed (DNFB) report, which tracks pending cases. An effective DNFB management system enables HIM staff to identify high-value and aged cases immediately, facilitating rapid resolution and maintaining optimal cash flow.

Medical necessity remains central to successful billing. Providers often verify medical necessity assessments just before claim submission. Close collaboration between billing and coding is necessary to prevent denials related to medical necessity. Coders contribute by querying physicians for clarifications and resolving coding edit conflicts such as Outpatient Code Edits (OCE) and Correct Coding Initiative (CCI) edits. These edits highlight discrepancies or conflicts in coding and billing that need physician input or system adjustments.

OCE and CCI edits are mechanisms designed by CMS to promote appropriate, non-duplicative coding, ensuring accurate reimbursement and compliance. Resolving these edits involves detailed review by coders and clinicians, highlighting the importance of an integrated team approach. Continuous efforts to streamline these processes and improve documentation accuracy are essential for reducing denials and optimizing revenue.

References

• American Health Information Management Association (AHIMA). (2020). Coding and Reimbursement Principles. AHIMA Press.
• Centers for Medicare & Medicaid Services (CMS). (2022). Outpatient Code Editor (OCE) and CCI Edits Overview. CMS.gov.
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• American Hospital Association. (2021). Strategic Revenue Cycle Management. AHA Publications.
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