As the distribution of COVID-19 vaccines accelerates and case numbers begin to drop in some parts of the world, it’s fair to say that many healthcare professionals are beginning 2021 with a renewed sense of optimism. That’s not to say there won’t be other difficulties, of course, and health information management (HIM) leaders and teams in particular face a fresh set of challenges this year.
New 2021 coding guidelines are the first obstacle that will complicate workflows for evaluation and management
(E&M) coders. Thus far, these individuals have dealt with either 1995 or 1997 guidelines, and the updates add a whole new set of considerations that could cause complications and result in payer denials or missed coding opportunities. According to the new guidelines, the code level of a visit will no longer be determined by patient history or a physical exam. Instead, physicians will base documentation on either the amount of time spent with the patient or the degree of medical decision-making required during the interaction.
In addition to the evolving standards, HIM teams are contending with staffing shortages. Pew Research findings indicate that 10,000 people reach retirement age each day in the U.S. And while the Bureau of Labor Statistics suggests that overall employment needs will increase by 0.5% each year from 2018 to 2028, jobs in the healthcare sector will increase by 1.6% annually — more than three times as quickly — over the same period.
To make matters worse, fewer staff members must now juggle more responsibilities, as the healthcare industry’s transition to value-based care makes accurate documentation more critical than ever. With the value-based care model, coding errors have major consequences, and they can potentially clog a hospital’s revenue stream due to delayed or denied payments.
Addressing the E&M Elephant
The 2021 guidelines don’t replace the ones from 1995 or 1997 for most payers, but that doesn’t necessarily mean hospitals should relegate their coding practices to the 20th century. To chart the best way forward through emerging E&M challenges, HIM leaders and teams should follow these four steps:
- Run simulations of new guidelines
Your coders would probably prefer to stick with the 1995 or 1997 guidelines — whichever they’re most familiar with — but that decision could cost you valuable revenue. To back up hunches with data, it’s a good idea to take several sample charts and simulate billing according to the new 2021 guidelines. No matter what ends up making the most financial sense, your team will learn something from the results.
Simulating a few charts is a great start, but HIM leaders can also run broader financial simulations to determine what kind of budgetary impact the hospital can expect per claim, per quarter, and even over the course of the entire fiscal year. This holistic view can help organizations plan their spending more accurately to ensure revenue cycles remain uninterrupted.
- Audit chart contents for consistency
The new coding guidelines will have different requirements in terms of documentation, and common templates like those used in electronic health records (EHRs) will need to be analyzed and possibly updated if key information is missing. If certain required fields aren’t being filled out consistently, reach out to the EHR vendor to ensure this information is added as a requirement in the updated template.
Templates for capturing the right information should also minimize or eliminate history or exam questions that aren’t medically necessary to make filling out forms as easy as possible. When it comes time to audit charts and ensure required information has been captured, rely on tools that are office-visit specific and include insights into how a Medicare administrative contractor would interpret documentation.
- Audit selected codes to ensure accuracy
The new coding guidelines will come with a learning curve, and it’s only natural for coders to make some mistakes during the transition. To help them along, computer-assisted coding (CAC) software powered by natural language processing (NLP) can parse through unstructured healthcare data and spot errors or omissions in coding. Because some payers allow for the usage of any of the guidelines, CAC can even look at individual charts and recommend which set of billing rules will bring in the most revenue for the organization.
CAC will undoubtedly increase coder productivity, but education is equally important. Training coders according to the new billing guidelines will help give personnel the skills and confidence to identify the correct guidelines for any situation, and code quality audits can help personnel learn from mistakes and continuously improve. It’s also important to cross-train coders to prevent a lapse in production when your highest flyers need to take some well-deserved time off.
- Prioritize physician education
It’s not uncommon for busy physicians to view documentation as an impediment to their work, but the truth is that quality documentation is a logical extension of quality care. When physicians repeatedly fail to capture pertinent information, it only makes coders’ work more difficult and increases the likelihood that potentially expensive mistakes will go unnoticed. That’s why it’s critical to train providers in proper documentation practices and educate them in the importance of coding to improve buy-in.
In the face of evolving E&M regulations, it’s a good idea to place providers on 100% review until they become more acquainted with the intricacies of 2021 guidelines. HIM leaders can also use tools like EHR smart links, smart phrases, and express lanes to automatically populate information and reduce the time and effort needed for providers to complete documentation. By investing in solutions that make the documentation process easier on providers, HIM leaders are investing in provider buy-in and a CDI-focused culture.
Outpatient and Ambulatory Care Challenges
New E&M guidelines will certainly complicate CDI in 2021, but HIM teams will also face challenges replacing revenue that once came primarily from ambulatory care. It’s increasingly apparent that the days of revenue coming from “heads in beds” are fading into the rearview. According to the American Hospital Association’s 2019 Hospital Statistics report, outpatient revenue was at 95% of inpatient revenue, and a Deloitte report found that outpatient revenue experienced a compound annual growth rate (CAGR) of 9% between 2011 and 2018 while inpatient revenue grew at just 6% annually.
Outpatient revenue is increasingly able to replace what used to come from inpatient services, but the importance of outpatient revenue places additional stress on CDI teams. In the inpatient environment, visits might last several days, offering plenty of time for review of coding and documentation to ensure that they support the claims being billed. In the outpatient environment, visits last an average of just eight to 40 minutes, with much higher patient volume and a rapid turnover rate.
The pace of outpatient care puts additional strain on both providers and coders, and HIM leaders and teams must deliberately work to overcome these challenges by focusing on the following four steps:
- Arm coders with necessary tools
Some HIM teams still rely on Excel or other spreadsheets, but accounting software leaves much to be desired in a CDI setting. Data from Black Book Market Research suggests that 90% of hospitals that implement a dedicated CDI solution improve annual revenue figures by $1.5 million or more, demonstrating a clear and immediate ROI from using the right tool for the job.
Any medical coding-specific solutions will be an improvement over Excel, but CAC is rapidly becoming an industry standard feature of the leading tools. This advanced capability will quickly pay for itself by closing persistent documentation gaps, increasing coder accuracy, and offering a holistic view of patient health.
- Target education to close gaps
When physicians make the same documentation mistakes repeatedly, it becomes increasingly difficult for overwhelmed coders to keep up. With the right solution in place, CDI staff won’t just have the capability to correct mistakes before they slip through the cracks — they’ll also be able to make training recommendations based on provider documentation performance.
By identifying knowledge gaps and areas for improvement, CDI tools actually help providers become billing and revenue cycle stewards, relieving some of the burden on coders and helping them contend with increased outpatient volume.
- Remove revenue cycle silos
With outpatient services moving to shoulder the revenue burden from inpatient procedures, it’s important to combine inpatient and outpatient revenue cycle management and gain a broader picture of utilization and revenue.
Holistic revenue cycle management also offers healthcare organizations a better glimpse into the populations that could most benefit from value-based care, which improves the quality of care delivered to these groups while helping providers stay on top of their finances. By tearing down silos between revenue departments, HIM leaders can maximize their impact in the shortest time.
- Prioritize outpatient risk scoring
The main criticism of the fee-for-service healthcare billing model is that it prioritizes quantity of services delivered over quality. The value-based care model is focused on optimizing patient outcomes, and although it’s gaining momentum in the space for good reason, it also amplifies the importance of accurate documentation and risk-scoring.
Without properly accounting for patient risk, healthcare providers and their organizations could end up footing the bill for care when it exceeds the anticipated scope outlined in documentation. One or two instances alone aren’t a big deal, but when this underestimation of risk happens across broad swaths of a population, it can snowball into a major problem for health systems. When HIM leaders look for ways to improve documentation associated with outpatient services, they must prioritize accurate risk-scoring procedures.
The twin challenges of evolving E&M documentation and increasing outpatient volume are critical to address because they both threaten to contribute to one more issue for HIM teams: claim denials.
Coping With Claim Denials
A 2017 survey from Advisory Board illustrates the magnitude of the claims denial problem, finding that hospitals were writing off 90% more denials as uncollectible than just six years prior. Appeals had also become less effective between 2015 and 2017, with success rates dropping from 56% to 45% for commercial payers and 51% to 41% for bills to Medicaid.
Whether they’re caused by missing documentation, duplicate codes, or incorrect plan codes, claim denials cost hospitals anywhere from 1-5% of net patient revenue. Payer-specific guidelines further complicate the billing process, and many payers are waiting until they receive the proper documentation to pay instead of issuing payment and later confirming that procedures were billed properly.
To protect vital revenue streams and ensure that care delivery can continue without financial complications or interruptions, HIM teams will need to be deliberate in their efforts to combat claim denials. At EZDI, we’ve purpose-built a dynamic solution.
With the CAC features built into EZDI CDI software, coders are more like auditors. Instead of having to manually scrutinize every square inch of documentation, coders powered by EZDI simply double-check documentation and investigate the errors or gaps highlighted by AI. This productivity boost helps organizations contend with staffing shortages while improving accuracy and protecting revenue cycles.
EZDI also arms HIM teams with sophisticated reporting capabilities, allowing leadership to monitor the progress of providers with scorecards and helping them stay informed of CDI initiatives via dashboards.
The EZDI Difference
Healthcare is becoming less about providers checking the right boxes and more about improving patient outcomes. That shift requires documentation detailing how the delivered services met the established needs of the patient.
Recognizing the need for a solution that could turn a wealth of unstructured healthcare data into insights to support CDI efforts, EZDI applied the power of AI to create a cloud-based platform capable of improving coder productivity and helping management maintain the revenue streams that are vital to providing care.
For more information about how EZDI can empower your organization’s CDI initiatives, reach out for a demo today.