Reimbursements: Oct 07

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Q. Revenues and reimbursements seem to be decreasing at an alarming rate. I feel like I’m working more for less. What about reimbursement opportunities—do they even exist?

A.  Reimbursement opportunities actually do exist, but alas, so few are maximized. The key is improving, not increasing, your documentation. Simplifying the challenges of the patient encounter by following the logical sequence of care given and documenting the record to meet and follow the Documentation Guidelines is the primary reimbursement opportunity.
Re-assessing the structure of your practice group may also be beneficial to your revenue stream. The use of qualified midlevels (PAs or NPs) to provide partial double coverage or as an alternative to 100% physician staffing for all shifts is a cost effective strategy to consider. Provided the PAs or NPS are employed or contracted by the physician group and are supervised according to Medicare and Medicaid requirements, their services can be billed on a fee for service basis. Documentation is once again paramount: if the physician provides and documents any face-to-face portion of the E/M encounter with the patient, the entire E/M service may be reported under the physician’s UPIN/PIN or NPI number. A shortage of physicians, cash flow or both can be addressed with the effective use of midlevel providers. Under this scenario, physician staffing schedules could experience improved efficiencies and become less demanding. Bottom line revenues should also improve as midlevel salary requirements are significantly lower than physician salaries.
Opportunities could also be identified through a formal review of your current coding processes. Outside audit feedback obtained is valuable information to assess and verify if compliance standards are being met and if appropriate revenues are being captured within the coding process. One quick indicator of your coding integrity is your acuity distribution. ED distributions should be bell curved with a slight shift to the right. Generally speaking, minor E/M level fluctuations may occur from month to month, but overall distribution should reflect stable patterns.
For many groups, improved bottom line revenues could be actualized with a review and update of fee schedules. During a fee schedule process, revenues can be improved by adjusting fees as well as adding services not previously included on the fee schedule (i.e. hydration, observation status services, pulse ox or after hour codes). When was the last time your fee schedule was updated? What services are included in your coding profile?
Sometimes it’s the little things that make an impact. A perfect example is EKG charges. Diagnostic EKGs are performed on 30—50% of the patients we see in the ED. CMS rules are specific on this issue: the physician who provides the contemporaneous read should bill for that service. While the individual charge value for an EKG is relatively low in comparison to other ED procedure charges, lost EKG charges can add up quickly. Consider this: Medicare average reimbursement for EKGs is $9.10. If 750 EKGs are performed each month, this results in $6,825 in monthly revenue or $81,900 annually. EKG interpretations should include at least three of the following six elements: axis; presence or absence of ectopy; rhythm or rate; PR intervals; ST wave changes; comparison to a prior EKG if reviewed.
We all ultimately know that revenue success is dependent on the documentation effort you use, the coding expertise you employ, and the billing company follow through. Pay attention to the details of your practice, look for additional reimbursement opportunities and you should experience improvements to your bottom line.


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