ACCA: Better in-hospital coding strategies can eliminate revenue drains

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ATLANTA--In order for providers to eliminate top revenue drains, they must adopt better coding techniques and integrate the coding team into the hospital setting, said Karna Morrow, from Coding Strategies in Atlanta, during her presentation at the American College of Cardiovascular Administrators (ACCA) conference on March 12.

Morrow explained that payors deny reimbursements for the following reasons:

  • 47 percent are services they deem as not medically necessary;
  • 23 percent have a lack of information to approve coverage; and
  • 17 percent are non-covered services.

She suggested that the 23 percent figure is what needs to change for hospitals to gain the appropriate reimbursements to make them more profitable, and get paid for the services they are providing.

“In hospital environments, we play by coding rules that are outdated, that do not apply to the physicians – we’re playing the game by the wrong rules,” she said. “A component of playing by better rules is better denial management. How a provider approaches its denial management will have a significant and immediate impact on the practice’s bottom line for services already provided.”

The accuracy of CPT coding on the provider’s part cannot guarantee payment by all payors and plans, according to Morrow, who said that providers must review the coding and coverage policies of each individual carrier with whom they are contracted.

She suggested that the hospitals have underestimated the positive impact of a team approach, encouraging providers to embrace the coding team into the framework of the hospital setting, especially due to the disparate nature of the various specialties.

“The nuances in the coding world are not consistent specialty to specialty,” Morrow explained. “For instance, how we code for a stent in various anatomical locations is different.”

She continued: “Hospital administrators are not doing the actual coding, and for the most part, they rely on staff behind the scenes to handle it, which is helpful because it is part of the team approach,” said Morrow. However, she also encouraged administrators to “ask some tough questions in order to ensure that their coders are properly recording what procedures were done.”

She mentioned the commonality of physicians improperly reporting what they do on a daily basis, and if it is improperly documented, the coders can not properly abstract what happened. “There are large gaps,” said Morrow, adding that Medicare Administrative Contractors now ensure that documents match, or they hold the claims and reimburse until they match.

“What was done is important, why it was done is critical,” she said, exemplifying the electrophysiology lab as a specialty that insurance companies “do not understand the value of the services rendered. "We have a tremendous opportunity to be educators."

When it’s appropriate, "speak CPT, and speak to the language of the payors, when possible,” Morrow said. Again, in the electrophysiology lab, if the definition of the CPT code speaks to “pacing” and “recording,” the coders should use that exact language.

The clinical staff and non-physician staff also need to understand CPT guidelines for the top procedures in order to communicate and document them properly. Likewise, she encouraged administrators to teach their coding staff about the clinical nature of the procedures they are coding for, especially because they are defending to the payors why a procedure shouldn’t get denied.

She acknowledged some of the difficulties of the coding world, including the constant changes, such as this year’s new codes for cardiac MRI or the add-on code for velocity flow mapping, which was previously not getting reimbursed separately.

To stay abreast of the changes, she encouraged hospitals to have their coders get certified.

However, she cautioned administrators not to rely on the coding team to abstract what wasn’t documented or to confirm what was done was documented.

Finally, denial management includes persistence and to be aware of time limits. “Sometimes, it may take several appeals before a procedure is reimbursed. However, that process requires all the parties involved to have understanding and to be on the same page,” Morrow said.

There is "a lot to consider” in the area of coding in order for providers to obtain the revenues for the services they provide, according to Morrow, adding that the