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Nearly all readers will know the famous line from the movie Forrest Gump: “Life is like a box of chocolates—you never know what you are going to get.” That is true for my life as a reimbursement strategy consultant: I never know what reimbursement question(s) I am going to receive when my phone rings or I open my e-mails.
Last month I received a call and provided consultation and education about a topic that keeps recurring. Therefore, I decided to share last month’s virtual consultation with you, hopefully to prevent you from experiencing the disaster that frequently occurs when the people on the revenue cycle team do not communicate with each other and do not work together.
A hospital administrator called and said he was very displeased with the results of a recent audit of the hospital-owned outpatient wound/ulcer management provider-based department (PBD) and the hospital-employed medical staff who work in the PBD. He said the PBD has been in existence for 9 years and rarely has any denied claims. However, the audit showed that the PBD and the medical staff owed money back for nearly every patient encounter that had been billed. The administrator was hoping that I could help him and the PBD director to identify the root cause(s) of this enormous repayment.
Facts to Consider
• Every member of the revenue cycle team must know the coding, coverage, and payment regulations for wound/ulcer management in a PBD and must understand how their work contributes to “clean claim” submission that will pass audits.
• The Charge Description Master (CDM) should include correct codes and appropriate charges for all the services, procedures, and products provided to patients during their PBD encounters.
• Every member of the revenue cycle team should know and comply with the code descriptions and guidelines for every code in the CDM.
• The guidelines provided by pertinent National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), and Local Coding Articles (LCAs) should be followed by every member of the revenue cycle team.
• The guidelines provided in the National Correct Coding Initiative (NCCI) Edits Manual and the procedure-to-procedure (PTP) edit files should be followed by every member of the revenue cycle team.
• The guidelines provided in the Outpatient Prospective Payment System and Medicare Physician Fee Schedule Final Rules should be reviewed and implemented every year when they are published.
To begin this investigation, I spoke with the PBD director and asked her to schedule a virtual meeting at a time that would be convenient for the hospital administrator and all the revenue cycle team members involved with documentation, coding, billing, and claim submission. The PBD director’s response to that request was surprising, “I do not know the people who check the coding, do the billing, and submit the claims, but I will find out who they are and will invite them.”
When the virtual meeting began, I explained that the goal of the meeting was to learn about the process that is followed in their facility from the time the patient is seen in the PBD until the time the claim is processed. Because I knew this was the first time many of them were speaking to each other, I asked every participant to introduce herself/himself and to describe her/his function in this process. Following are some of the process issues that we learned:
• The PBD director never reviews the department CDM to be sure it is functioning as planned.
• The PBD staff and the medical staff, who are employed by the hospital and work in the PBD, do not use the NCDs, LCDs, and LCAs to guide them in their medical decision making and clinical documentation. In fact, the PBD and medical staff never read the documents because they say that is the job of the coding and billing department. However, the coding and billing staff reported that they did not read the NCDs, LCDs, and LCAs because that was the job of every department to know their own rules!
• The PBD staff select and report the codes that represent the work they perform, and the medical staff select and report the codes that represent the work they perform. They do not know many of the code descriptions, including the code units. Some of the PBD and medical staff reported that they select the code(s) that “pay the most.”
• Neither the PBD staff nor the medical staff read the NCCI edit manual and do not know that they can easily filter the NCCI files to learn about PTP edits. Therefore, they do not know that many of the procedures that are performed during the same encounter should actually be packaged together for payment purposes.
• The coders never read the documentation from the PBD or the medical staff. They simply add modifiers to the codes that hit an NCCI edit—they add whatever modifier they know will allow the claim to pass through the system. That means they are telling the payers that all the procedures, performed during the same encounter, are performed on separate anatomic locations, which is rarely true.
• Upon my request, the CDM manager reported how the PBD’s CDM functions:
o When the “Q” code for a cellular and/or tissue-based product (CTP) for skin wounds is reported, the CDM always reports a unit of 1: that tells the payer the physician only applies 1 square centimeter of the CTP, yet the application code reported is usually greater than 1 square centimeter and is often more than 25 square centimeters.
o The CDM only lists the clinic visit code G0463 with modifier 25, which means that every time a minor procedure is performed and a clinic visit is reported, the clinic visit is paid even if a significant separately identifiable evaluation and management (E/M) service was not performed.
The CDM manager also reported that the medical staff’s side of the billing system does not include selective debridement codes (97597 and 97598) and only includes levels 4 and 5 E/M codes. That means the medical staff reports that they debride subcutaneous tissue, muscle, or bone even if they only debride epidermis, dermis, slough, exudate, biofilm, etc. It also means that the medical staff never reports levels 1 through 3 E/M services; it is highly unlikely that every medical staff visit entails level 4 or 5 work.
• No one on the entire revenue cycle team recalls ever conducting an internal audit of the PBD and of the medical staff who work there. Therefore, they were totally blindsided by the results of the payer’s audit that resulted in an enormous repayment.
By the time this virtual meeting ended, it was clear to the hospital administrator, to the attendees, and to me that their revenue cycle process for the PBD and the medical staff was clearly broken. In fact, the administrator told me he had no idea how much the various departments worked in silos, that the personnel who contributed to the revenue cycle did not know each other until that meeting, that no one was accountable for knowing the reimbursement guidelines, and that no internal audits had been performed for this PBD and its medical staff. We learned all of this in one 90-minute virtual meeting.
Then the longer, harder work followed: repairing the broken process by educating all the pertinent revenue cycle team members about the unique coding, coverage, and payment guidelines for wound/ulcer management, and how they had to work as a team to document thoroughly, to code accurately, and to submit “clean claims” that will pass internal audits (which they will conduct monthly) and future payer audits.
Because I have been contracted to consult on similar scenarios many times each year, I am encouraging readers not to assume this problem is not occurring in your PBD or office. Take the time to meet with your entire revenue cycle team and learn what happens from the time the patient encounter occurs until the claim is submitted. If any part of the process needs refinement, work together to provide the appropriate education and to make the needed changes. Then select topics that should be audited and conduct monthly internal audits until you are sure you can pass payers’ audits. During audits you may actually find errors that caused underpayments!
But remember, none of this can happen unless the members of the revenue cycle team know each other and work together towards achieving a common goal: to get paid appropriately and compliantly for the work performed in the PBD and by the medical staff, and to keep your payment after payers’ audits.
Kathleen D. Schaum oversees her own consulting business and is a founding member of the Today’s Wound Clinic editorial advisory board. She can be reached for consultation and questions at firstname.lastname@example.org.