Developing the Coder's Role in Revenue Cycle Management

Dorothy Hattan, CCS, CPC

In 1995, AMC combined the hospital and clinic to become a hospital-based provider facility in addition to becoming an affiliate of the Mayo Health System. This required a complete retooling of the financial system, and the CFO had the foresight to realize that this was going to require many staff members, clinical and financial, to create a new and improved process to keep the facility financially stable.

The revenue cycle team approach has been around for sometime, but only until recently have hospital CFOs realized that revenue cycle improvement requires all the members on the team from within the facility—starting at the front end (registration) through the clinical departments to the accounts receivable (AR) department. AR management requires daily, weekly, and monthly monitoring by several members of the revenue cycle team, such as the AR manager, medical revenue systems (MRS) manager, finance manager, and importantly, the CFO.

The idea of the revenue cycle team management brings together all the elements that affect not only cash flow but also patient care. All clinical and financial department managers need to take ownership for their department’s piece of the revenue cycle. They should continually review those performance indicators that will keep the level of patient care, patient satisfaction, and cash flow in alignment with the goals of the organization.

At Austin Medical Center, the focus starts on the front-end processes—registration. The collection of the correct patient demographic and insurance information is key to a clean claim and making sure that the proper information is submitted to the payer. The collection of charge data can be either through an electronic system, such as order entry performed by ancillary staff pulling charge codes from the chargemaster dictionary (CDM) to the claim, or via charge tickets that the physician, nurse, or other ancillary staff marks manually. The chargemaster dictionary and the service record (or fee ticket) are communication tools that convey codes (CPT procedural or ICD-9 diagnosis codes), dates of service, in addition to provider name. If these tools are not accurate, inclusive and up to date, the result can be inaccurate charges, loss of charges, and decreased or lost revenue. Technology is an important tool in providing an efficient and safe environment for producing clean claims. The database system used for data collection and billing must be capable of providing and supporting the different types of claims (HCFA-1500 for physicians and UB-92s) for any payer in the required HIPAA electronic format. The electronic environment of claims production and remittance vouchers has the ability to shorten the DRO.

Departments such as medical revenue (or HIM) are responsible for keeping or assisting in the maintenance of the charge tickets and chargemaster. Having credentialed, experienced coders within the MRS department in addition to the correct, updated resources (such as an encoder) enhance the production of a clean claim. At AMC, the MRS coder for hospital claims is not only responsible for coding and abstracting ICD-9-CM diagnosis codes, procedure codes, and/or CPT-4 procedure code, but also verifying the charges that upload from the billing system into the abstract system. Currently for government payers, the billing system uploads the charges that are residing on the outpatient account or any professional fees for the hospital charges, such as radiology, into the abstract system. Once the coder enters the abstract and links to the encoder through a batch interface, the charges attached to the encounter upload to the encoder and specific coding, OCE, or CCI edits will invoke a warning to the coder to address. The coder can then address any medical necessity, modifier, or CCI edit for the charge prior to submission to a claim scrubber. Once an encounter is coded and finalized, the claim then uploads electronically to the claim scrubber, and the next day any claims that fail an LM (medical necessity edit) or OCE/CCI edit will be assigned to the coder to review and correct and then resubmit for claim processing.

While many consider this a process belonging to the claims processor or biller, this is a process that requires the knowledge of a certified, credentialed, experienced coder to handle. Denied claims are identified immediately and are electronically returned to the MRS department for review versus the old paper process of returning on a paper remit, transferring to a paper rejection trending form, review by a coder, and return to the AR staff for a written appeal, phone review, or adjustment. The manual paper process can take anywhere from 30–45 days post charge submission. The creation of a denial management team at AMC brought together key team members from AR and MRS. They identify recurring scenarios that cause claim denials that can be dealt with quickly and efficiently. With coders becoming more involved in the charge process and not “just coding” the range of their knowledge is more critical and requires an understanding of the total revenue cycle.

The creation of the Revenue Cycle Team of AMC brought together dedicated, talented professionals that believe in the values and goals of AMC. Expanding the focus beyond finance to include the front- and back-end departments (registration and coding) through the use of technologically enhanced systems has increased cash flow, solidified the financial stability, and provided the necessary funds for future growth.

AMC’s 2005 growth plan calls for an $18.5 million construction project that will be financed almost entirely by capital funds with additional foundation funding. Resources from organizations such as HFMA assist facilities like AMC in identifying on a yearly basis as to how they are doing, and what processes need evaluation and potential change. For AMC, the past seven years have seen a constant change, yet with the implementation of the revenue cycle team, billing and collections has become more effective, productive, accurate, and positive financially. Expanding the focus of improving billing and collections to improving all process from the front end to the back end has provided AMC with the financial stability that some larger hospitals do not have. Much of this can be credited to the foresight and talents of the CFO who has been willing to invest and trust in the talents of his employees.

Hattan, Dorothy. "Developing the Coder's Role in Revenue Cycle Management." AHIMA's 77th National Convention and Exhibit Proceedings, October 2005.