Correct procedure coding is a primary, and pivotal, activity among providers and payors alike. Undercoded claims leave money on the table, while overcoded claims leave the practice exposed to financial risks, including potential accusations of fraud. If a practice spends too much time on coding, reporting, reviewing, scheduling, code approval, and amending reports, the practice will suffer as turnaround times increase and staffing expenses soar.
What if you knew, though, that more than 99% of your practice’s claims were correctly coded? Would your practice bring in more money? Would you sleep better at night, knowing that you were not at risk for repayment and/or fraud accusations? How can correct coding be achieved while improving, not harming your practice or patient care? All of these questions provide a framework for establishing a simple, yet necessary, system for ongoing audit and review of your coding practices.
About a year ago, I introduced myself to ImagingBiz.com’s readers as Inland Imaging’s new chief reimbursement officer (CRO). As the company’s CRO, I am responsible for maximizing the revenue delivery of our organization by implementing and managing billing and contract practices that accelerate and enhance billing services.
In that article, I discussed Inland Imaging’s plans to improve coding through audits, education, and operational process improvements. What follows is an update on what we’ve done so far, challenges that we overcame, progress that we have made, and our plans for continued improvement.
The Audit Process
If your practice is like most, codes included on the claim are generated in one or more of the following ways: by importing codes from the hospital and/or imaging center; by professional coders manually coding from the provider’s report; and, increasingly, by the use of a natural language processor to abstract from the provider’s report with coder oversight.
Inland Imaging uses each of these three methods, depending on the practice site, as a result of its service delivery through hospitals, owned imaging centers, and third-party management agreements. We began by randomly selecting claims from each modality, and we then audited the claim from the starting point to the closure of the claim (essentially, A to Z). Recognizing that there are several potential trouble points, we developed a tool within which we recorded the variances
- between what procedure was ordered (both initial and revised) and what procedure was performed (as documented within the RIS through technologist notes, nursing notes, and so forth);
- between what procedure was performed and what was substantiated in the radiologist’s report; and
- between what procedure and outcome were substantiated by the radiologist’s report and what was actually billed.
Given the manual process required for this level of research, we necessarily limited our audit sample to 200 to 300 randomly selected claims annually per modality, which for us was between 0.5% and 1% of the annual total for CT and MRI.
What We Learned
So far, we have completed a comprehensive review of both CT and MRI through the audit process. Because corporate compliance is of principal importance, we initially focused on the differences between the coding substantiated by the physician’s report and the coding ultimately submitted to the payor. Key learning: We found that in using only the radiologist’s report to substantiate coding, we invariably ignored the balance of the medical record. Thus, for every two claims that were overcoded, three were undercoded.
Digging a little deeper, we discovered that the coding submitted to payors was actually closer to what was actually performed, and that that the technologists in the core were better at reflecting the level of service performed than the doctors were in getting all the necessary information into the report. Key learning: Use the expertise of the technical team to identify and correct miscoding initially.
Often, the radiologist’s report did not address all components necessary to substantiate the claim. The most common errors included the failure to mention the use of contrast in the report (the need for or administration thereof), and/or failing to document all views that substantiate a complete versus limited examination. Key learning: Do not rely solely on the outbound report as the basis for proper coding.
Faced with the knowledge that our billed codes do not always sync with the level of detail included in the radiologist’s report, we acknowledged the need to make specific improvements. The Inland Imaging board of directors will soon determine whether to implement a natural language processor solution between the radiologist’s report and the billing system for all claims from all facilities, or to facilitate a new requirement that a technologist, a coder, or a transcriptionist in the center (or the core) review the report and ensure that the RIS and the billing data match the radiologist’s final report.
These would facilitate the timely amendment of the report and also ensure accurate billing to the patient and the payor. Each of these options comes with inherent pros and cons, and Inland Imaging will determine a permanent solution in the very near future.
Primary Challenges
Whatever systematic solution we choose, one thing is now clear: For correct coding to occur 99% of the time, we must improve our documentation within the report.
Professional opinions differ as to the ability of RIS data to substantiate coding outside the documentation in the radiologist’s report, but there is little doubt that the report serves as the primary source document and that it should be as comprehensive as possible.
In order to help the radiologist document all components of each examination, Inland Imaging is creating standardized report templates, or skeletons, that assist the provider in following Inland Imaging’s adopted structure. These consist of the examination title, the clinical history, the procedure, the findings, and the conclusion.
With standard verbiage already completed, together with prompts for variable data and unique findings, these templates are easy to access and easy to complete. A template is designed for each examination code and each of the procedures inherent in that examination code.
To create a robust product and gain acceptance from all providers, we have obtained the recommendation of the practice’s coding and reimbursement committee to implement these templates. Our professional coders bring forward recommended templates that meet all coding criteria. Further, assigned lead physician representatives from each subspecialty review and approve the templates brought forward by the coders. Each recommended template follows the same general structure described earlier.
Conclusions and Outcomes
Simple extrapolation of our findings indicates that Inland has a $1 million revenue opportunity based on the implementation of this process (recall that we found three undercoded claims for every two overcoded claims), along with a reduction in our exposure to compliance risk.
Assisting the providers by developing standardized templates that adequately address each procedure and the findings within an examination is part of the solution. Using that report to derive billing codes—even if the technologists are already coding from the examination within the core or in the center—will result in a match as good as a natural language processing/external coder solution.
Based on our findings to date, these audit enhancements will both increase compliance and return significant profit to the practice.
