Reimbursements: Where to Begin?

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Q. Maximizing Reimbursements
Our group is trying to assess and determine what direction to take with coding. We’re stumped and don’t quite know where to begin. Any suggestions?

Q. Maximizing Reimbursements
Our group is trying to assess and determine what direction to take with coding. We’re stumped and don’t quite know where to begin. Any suggestions?

A. The three cornerstones to optimizing appropriate revenues while minimizing compliance risk are quality documentation, coding and billing. You are wise to take a good look at all three components.
Coding services have and can be provided in a variety of ways:
In-house coding: coding performed by hospital employed coder, physicians, nurses, EMR.
Outsourced coding: coding performed by professional coding vendor or as part of billing company services.

The integrity of the coding process can have a significant impact on your individual and practice reimbursement and risk. Key factors to consider for either in-house or outsourced coding are:

Cost of Coding: If you currently have or are considering traditional in-house coding, then you will need to take out your calculators and start adding up the wages for ED coders, supervisors, benefits, taxes, office overhead and other miscellaneous expenses. Once you have the sum of those figures all calculated, then divide by the number of ED visits coded per year. This should yield the in-house “cost for coding per record”. If you are outsourcing your coding services, then the line item cost is easy to derive. Services are generally priced on a per record basis.
Now the “true cost” of coding involves much more than the above calculations. Please beware: if you are approaching coding from a cost line item perspective alone, you may find yourself penny rich and dollar poor. The difference in bottom line revenues that results from expert coding services versus average coding far exceeds any per chart price point/cost differential. Get out your calculator again to check out what a potential 3 – 5% right shift in your acuity levels would be and you will see what I mean. There is definite value to be gained from expert coding! Accurately coded charts that capture the appropriate E/M levels and all procedures performed can and will have a dramatic impact on your bottom line revenues.
Many of the new EMRs are designed to “recommend” E/M level and procedure code assignments through an artificial intelligence platform. Please note that this form of coding is NOT sanctioned by CMS. A human coder must still review the entire record to determine and verify the code assignment(s). Any proposed or marketed coding “cost savings” is unlikely.

Experience level and credentials of coders: Emergency medicine coding is complex. The coding function should be performed by certified coders experienced in ED coding.

Coding compliance plan: Internal compliance reviews should be conducted on a regular basis throughout each year in conjunction with a written internal coding compliance plan. External audits may also be obtained on an annual basis. New emergency medicine directives are developed annually and as the rules change, so does the reimbursement and compliance risk. Coder education is an essential part of an internal compliance plan. Education on new coding initiatives, coding clarifications should be provided on an ongoing basis.

Documentation feedback: Coding is directly dependent on the documented medical record. Documentation feedback and education should be an ongoing part of the coding process. A complete, thoroughly documented chart that accurately reflects the patient encounter is integral to the health and wealth of your practice.
Sharon L. Nicka, RN, CPC |


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