must be merged with hospital-based outpatient coding
and billing. Coders who have primarily performed professional coding now must collaborate with the hospital-based outpatient coders. Merging the two can be tricky
because each group has had distinct training and has its
own specialized knowledge. It is important to determine
the hospital coders’ level of expertise with professional fee
Keeping up with coding changes: Coding changes can
occur on an annual basis and should be updated and
reviewed routinely to ensure accuracy. Use of outdated
codes is a root cause of inappropriate charges, increased
denials, time-consuming appeals, and delayed reimbursement.
Meeting medical necessity: The concept of medical necessity is a major factor on the outpatient side, more so
for hospitals. Without an effective process for checking
medical necessity on the front end and without proper
documentation and coding to support a valid diagnosis,
hospitals sometimes write off the low-dollar cost of outpatient diagnostic tests rather than attempt to fix the problem or resubmit claims. A recent Advisory Board update
shows a surge in medical necessity denials, indicating the
challenge many facilities face, particularly those without
a clinical defense infrastructure.
Shifting to value-based care: The shift from volume to
value requires outpatient physician practices to prioritize
wellness and preventive care, which means a shift in how
information is captured. For example, consider chronically ill patients who need greater attention to keep them well
and out of the hospital. Documentation and coding must
be completed properly to ensure chronic conditions and
preventive treatments are captured according to value-based purchasing criteria. Some quality initiatives have
specific requirements for certain treatments and conditions. Failure to check the right boxes and provide the
right documentation can potentially reduce payments.
Six Strategies to Improve Outpatient Revenue Integrity
How can providers build quality to ensure optimal outpatient
coding, documentation, and revenue integrity? Consider the
following proven strategies:
1. Build a multidisciplinary team: Include members from
health information management (HIM), coding, clinical
documentation improvement (CDI), physician practices,
managed care contracts, revenue cycle, legal, IT, financial, denial management, audits, and compliance. Meet
on a regular basis to identify issues, develop strategies,
and assess outcomes.
2. Conduct chargemaster review and maintenance: Rou-
tine chargemaster cleanup helps eliminate claims ed-
its and denials by ensuring all codes, supplies, and rev-
enue codes are current and accurate. The main focus of
a chargemaster review is to confirm accuracy of CPT and
HCPCS codes. Because these codes are hard coded in the
chargemaster for most ancillary departments, an annual
review for new, revised, and deleted codes is recommend-
ed to ensure accurate payment.
3. Provide ongoing coder training and education: Ongoing
education for outpatient coders is critical to compliance
with quality-based reimbursement initiatives, so be sure
to assess the skills, knowledge, and experience of professional fee coders and hospital-based outpatient coders.
Acknowledge differences and develop a training and education program that builds competencies and encourages
4. Consider a single-path coding model: Some organizations have successfully transitioned to hospital and physician coding performed by one coder. With proper education and cohesive teamwork, single-path coding is an
effective way to streamline workflow, reduce costs, and
ensure greater integrity and consistency.
5. Ensure medical necessity up front to avoid issues with
claims edits and denials: The clinical documentation
must clearly state the reason for outpatient services, such
as C T scans, MRIs, lab tests, or same-day surgery. Coding,
CDI, and physicians should work together to ensure that
complete and accurate clinical support is provided for reviewers to acknowledge medical necessity. Though medical necessity software built into the EHR can be useful,
technology is not a standalone solution.
6. Promote communication among all areas involved in
the denial and appeal process. Work collaboratively to
create a denial management process from a root-cause
perspective aimed at denial prevention to support timely,
It’s All About People, Process, and Technology
Addressing the complexities of outpatient services and the impact on revenue cycle outcomes requires strategies to assess
risk, evaluate IT assets, streamline processes, manage human
resources, and more. HIM professionals have an opportunity
to lead efforts that ensure outpatient services are properly captured, billed, and reported. Their expertise is essential to achieving outpatient revenue integrity. ¢
Keith Olenik ( firstname.lastname@example.org) serves as a health information management subject matter expert at Pivot Point Consulting.
Quiz ID: Q1929009 | EXPIRATION DATE: OC TOBER 1, 2020
HIM Domain Area: Clinical Data Management
Article—“Six Strategies to Build Outpatient Coding Accuracy
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Six Strategies to Improve