revenue_worksheet xcoding_connections_in_revenue_cycle_management
Coding is a critical component of the Health Information Management Department and coders play an important role in the Revenue Cycle Management process.
“Revenue cycle management (RCM) is the process of managing claims, payment and revenue generation. RCM encompasses everything from determining patient insurance eligibility and collecting co-pays to properly coding claims. A well-designed RCM system is able to communicate with the EHR and accounting systems to streamline the billing and collection cycles.” (HealthIT, 2015)
This activity will introduce you to RCM and the role coders play in this function.
Be sure to read the attached article and complete the attached worksheet
Why is it important that the MRN connect the patient documentation to the services provided?
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Who should assign patient type to the patient?
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Explain why coding staff should have access to source documentation.
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Why is it a good idea to have front-line staff and coding staff working together?
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Can the revenue cycle process be affected by coding staff? Can you give a reason?
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In the hospital setting how are routine diagnostic services such as lab and radiology services charged to the patient?
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How do they determine which codes belong in the charge master and not coded by a coder?
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Why should concurrent clinical documentation management programs and query processes by implemented?
List 2 reasons coding quality and productivity standards should be established:
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Why do revenue integrity teams need coding professionals?
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What are the 2 key revenue cycle components that occur in patient financial services?
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Why is it important for HIM to have an effective DNFB Reporting tool?
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What function do coders perform that helps to reduce the number of medical necessity denials?
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What are OCE and CCI Edits?
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Copyright ©2005 by the American Health Information Management Association. All rights
reserved. No part of this publication may be reproduced, stored in a retrieval system, or
transmitted in any form or by any means, electronic, photocopying, recording or otherwise without
prior permission from the publisher. (2017-2019)
Coding Connections in Revenue Cycle
Management
by Ruth Cummins, RHIA, CCS, and Julie Waddell
Recently, there has been a significant amount of talk in the healthcare industry about revenue
cycle improvement. So what is all of the excitement about? It is about the bottom line.
Specifically, how we can improve our bottom line through more effective and efficient revenue
cycle management. For hospitals to maintain financial viability under the pressures of the current
healthcare environment, the revenue cycle must be a significant focal point, and HIM and coding
professionals should play major roles in the process. This article will highlight many of the
coding connections for the key revenue cycle processes within patient access, HIM, and patient
financial services.
The Coding Connection in Patient Access Services
Critical revenue cycle processes that occur in the patient access department include initial data
collection (e.g., name, date of birth, insurance information, reason for admission, patient type);
medical record number (MRN) assignment; and medical necessity determination. Coding
connects (or needs to connect) with patient access services in the following areas: MRN, patient
type, source documentation, and medical necessity.
The MRN is vital in connecting the patient documentation to the services provided to the patient.
If an inaccurate MRN is used, complete and historical clinical information may not be available,
resulting in potentially incomplete or inaccurate code assignment. Regular communication and
collaboration between HIM and patient access to maintain accurate MRN assignment is
imperative.
The patient access department, in many facilities, is responsible for assigning the patient type
(e.g., inpatient versus observation patient). It is very frustrating for the coding staff to have to
alter a patient type post-service due to inappropriate assignment. This correction process slows
down the revenue cycle. The coding staff should collaborate with patient access in identifying
ways to resolve inaccurate patient type assignments.
During the scheduling and patient registration process, test order documentation, including
reason for the test, should be presented. Source documentation is critical for the final code
assignment. Coding professionals should be involved in educating front-line personnel (i.e.,
those registering patients) regarding appropriate test order requirements. The coding staff should
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also have access to the source documentation when coding to ensure complete, accurate, and
consistent coding.
Hospitals and healthcare providers must determine if services will be covered based on the
reason for the test prior to services being rendered. In most healthcare organizations, this is left
to the front-line staff in patient access. Often, these individuals are in entry-level positions with
little or no healthcare background. Connecting the patient access department with coding
professionals is critical in complying with medical necessity requirements and reducing the risk
of denials on the back end.
Although it is not always feasible to employ a coding professional in patient access, healthcare
providers should consider creating a coding liaison position to assist patient access in
determining medical necessity and following up with physicians on proper test orders. Coding
orientation courses should be provided as a requisite for patient access staff as well. The revenue
cycle can be dramatically affected by connecting coding to the patient access process.
Documentation, HIM, Coding, and Chargemaster Services
Key focal points in documentation, HIM, coding, and chargemaster services that affect revenue
cycle performance include who assigns the codes; source documentation; coding quality and
productivity; and revenue integrity.
Healthcare providers must determine where CPT and HCPCS codes will originate, or “who
codes for what.” Information system requirements should be considered when determining
whether a code will be generated with a charge (i.e., hard-coded in the chargemaster) or whether
the code will be assigned by coding staff based on source documentation.
Typically, routine diagnostic services such as lab and radiology are hard-coded in the
chargemaster while surgical interventions are normally assigned by a coder. Lack of
coordination between coding and chargemaster staff can cause conflicts, duplicative coding, and
billing errors.
When determining whether a code belongs in the chargemaster or if it should be coded by a
coder, ask yourself the following questions: “Is the code always the same for the procedure or
service provided?” If yes, then the code likely belongs in the chargemaster. “Is coding
assignment variable, contingent upon site, method, or complication?” If yes, then the code
should be assigned by a coder. “Are there variables inherent in the documentation that would
modify the code?” If yes, then the code should be assigned by a coder.
Equally important as who codes for what is the source documentation a coder uses to assign the
appropriate ICD-9-CM and CPT or HCPCS code. As we all know, if it was not documented, it
was not done. Whether the code is hard-coded in the chargemaster or is assigned by a coder, the
source documentation must paint a clear picture of the clinical condition of the patient and the
services provided. Often clinicians will witness services being provided; however, final dictation
or documentation may omit specifics, which allow additional codes or charges to be added.
Coding plays a critical role in validating source documentation for coding and billing purposes.
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Concurrent clinical documentation management programs and query processes should be
implemented to ensure physician documentation appropriately reflects the clinical picture of the
patient and the services provided so that accurate and complete coding and billing can be
accomplished.
HIM departments should establish coding quality and productivity standards. Ongoing internal
and external quality audits are essential to ensure both compliance with coding rules and
regulations, and appropriate payment for services. Coders need to keep current on coding and
payment guidelines through continuing education and regulatory alerts and updates. To improve
the efficiency of the revenue cycle (specifically, to reduce the discharged not final billed cases),
coding productivity standards should be in place with a tool to effectively monitor daily
progress.
Revenue integrity is the process of validating documentation, charges, and codes to ensure
complete, compliant, and accurate billing and coding processes. A good revenue integrity team,
which includes coding professionals, identifies lost charges and coding issues along with
providing education and the development of processes to improve this component of the revenue
cycle.
The Coding Connection and Patient Financial Services
Of the many activities that occur in patient financial services (PFS), two key revenue cycle
components are billing and denial management. Data collected from patient access, information
from the chargemaster, and HIM coding all come together in the form of a bill. Sophisticated bill
edit systems have the ability to apply Medicare medical necessity, Outpatient Code Edits (OCE),
and Correct Coding Initiative (CCI) edits to the claim prior to submission. Once these edits are
applied, someone knowledgeable in coding and clinical protocols must resolve the edits to try to
avoid claim delays and denials.
Coding connects (or needs to connect) with PFS in the following areas: discharged not final
billed (DNFB) monitoring; medical necessity; OCE and CCI edits; and payment
verification.
Every HIM department should have an effective DNFB reporting tool. HIM staff should be able
to quickly identify high-dollar cases and the oldest cases. A process should be in place to quickly
address the cases identified. Goals should also be set (e.g., one day over the bill hold days), and
aggressive monitoring should be done on a daily basis. Significant communication and
collaboration among the entire revenue cycle team is required to maintain the DNFB at industry
best-practice standards.
Medical necessity does not take place only in the patient access area. Most billing systems allow
providers to check for medical necessity one last time prior to claim submission. Connecting the
billing process to coding is critical in reducing the number of medical necessity denials. Coding
professionals are key players in querying the physician a final time for additional documentation
to support services ordered and performed.
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Coders are also critical in resolving OCE and CCI edits. Edit conflicts may be caused by a
number of reasons, including lack of knowledge by the clinician entering charges and codes
coming from both the chargemaster and the coding process. Coders should be involved in the
daily bill edit process in order to avoid delays in final billing and claim rejections. Coders can
resolve difficult edits by removing an inappropriate charge, recommending a chargemaster
change, or evaluating source documentation to ensure complete and accurate coding. Some bill
edit systems allow specific edits to be driven or assigned to certain individuals or departments.
Edits such as comprehensive, component, and mutually exclusive should be assigned to a coder
for resolution.
Finally, a verification process should be in place to ensure expected payments are received on
both the outpatient (APC) and inpatient (DRG) assignment.
For healthcare providers to survive under the surmounting financial and operational pressures in
an ever-changing environment, the coding process must be connected to the key services within
the revenue cycle. Ongoing teamwork between coding and the areas of patient access,
chargemaster maintenance, and PFS creates an exciting opportunity for HIM and coding
professionals to spotlight their leadership skills. Make sure you are connected!
Ruth Cummins (rcummins@accretivehealth.com) is director of client services and Julie
Waddell (jwaddell@accretivehealth.com) is director of compliance at Accretive Health, a
revenue cycle management company, in Chicago, IL.
Article citation:
Cummins, Ruth, and Julie Waddell. “Coding Connections in Revenue Cycle Management.”
Journal of AHIMA 76, no.7 (July-August 2005): 72-74.
mailto:rcummins@accretivehealth.com
mailto:jwaddell@accretivehealth.com
