Cath Lab Revenue Recovery & Reimbursement The Tip of the Iceberg

Our original 2001 article generated a substantial response from Cath Lab Digest readers across the nation. It seemed that many cath lab programs were also looking for methods to improve revenue recovery at that time. (We would be interested in learning how many readers actually went ahead with their own programs, and of those who started a program, how many experienced the growth in awareness that we did.) We quickly became aware that revenue recovery is like an iceberg. The three issues that we tackled at the initial introduction of our program [lack of documented medical necessity in the chart, incorrect coding edits on the bill, and internal processes waiting on dictation and Charge Description Master (CDM) opportunities] were just the tip of the iceberg. The Revenue Recovery program within the cath lab at Morton Plant Hospital began in August of 2000 as a 90-day pilot program. Based on the effectiveness of that pilot, a full-time position was created within CV Services for a team member to be responsible and accountable for revenue recovery and reimbursement issues. After one year, we shared our experiences and results in the December 2001 Cath Lab Digest article. However, we didn’t stop our progress! The program has grown considerably in the years since, and in fact, our current program differs greatly from our original program. Our perspective quickly changed as we moved from those issues that could be easily seen to discovering what lay hidden below the surface. From the onset, our focus was on changing the culture and the attitude within the cath lab as a clinical department. We made revenue recovery and reimbursement everyone’s job. From the cath techs to the physicians to the secretaries and administration, we taught about issues that would impact revenue. Then we held people responsible for performing actions that would have a positive impact on revenue or reimbursement. Our initial process, which was largely driven by the reimbursement coordinator, has evolved into our current practice, which is driven by different sources depending on needs. If the reimbursement coordinator becomes aware of a change in payer policy about which other departments should know, an educational meeting is scheduled or an email is sent. If the manager of the cath lab decides to begin using a new product or perform a new procedure, the reimbursement coordinator is notified and makes the necessary changes to the CDM. The coordinator also reviews the Witt software for any needed documentation changes. If a hospital department is having issues with cardiology patients regarding payment or status, they contact the reimbursement coordinator, who works with the cath lab administration and techs to change processes to meet the other department’s needs. At present, the reimbursement coordinator is not necessarily the initiator of education and/or changes, but rather a true coordinator moving information as regards department needs from one area to another and assisting to bring about improvements via process changes. We found that our opportunities could be narrowed down to three main areas that many hospitals struggle with: Correct Coding Initiative (CCI)/Outpatient Code Editor (OCE) edits Medical Necessity issues Unbilled accounts (which we labeled internally as Outpatient (OP) Exception opportunities.) Our Finance Department was able to provide reports listing accounts which had not been billed and were related to one of these three areas. The reimbursement coordinator (a cath lab RN who has become our resident expert on reimbursement issues) worked the three reports to move bills along so that they were sent to payers as quickly as possible. Our reimbursement coordinator developed relationships with staff in key departments in the hospital that could assist in removing the barriers to bill drop in one of the three main areas. Our results are displayed in Figure 1. This was not a bad start, but a great deal has happened with our revenue recovery program since then. We now have an established culture of awareness and responsibility pertaining to revenue and reimbursement within the cath lab. Team members with knowledge of revenue and reimbursement now mentor new hires. The importance of revenue and reimbursement is taught to new employees from day one. The three reports that required so much work initially have evolved into improved processes that are now second nature, requiring only maintenance and supervision. As this evolution occurred, our director and reimbursement coordinator were motivated to search for other opportunities within the cath lab and in other departments, both within cardiovascular services and outside of our service line. Outside of the cath lab, but still within cardiovascular services, reimbursement recovery efforts were expanded to other cardiology-related departments such as electrophysiology, echo, EKG, and cardiac rehab. These efforts included medical necessity surveillance for echocardiology procedures and cardiac rehab visits. The results from the tuning of the cath lab chargemaster were expanded to other department CDMs, such as electrophysiology and echocardiology. Based on our success, initiatives that were successful within cardiology were taken outside of cardiovascular services into departments such as respiratory care and radiology. In addition to the three main areas of initial focus, we found numerous opportunities for loss of revenue and reimbursement in the cath lab. Sometimes it seems as if the whole payer-world is against the hospital receiving proper payment for the services we provide! Our program at Morton Plant has expanded into areas such as proper patient status, alerting key departments to changes in technology and coding, documentation, and auditing payments. We’ve transitioned from culture change and error reduction to investigating new opportunities to improve revenue and reimbursement all within the cath lab. Opportunity #1 - Patient Status We were able to meet with our case management department to learn appropriate post-procedure status for our large-volume procedures. We learned that different payers have different criteria for status changes. In the cath lab, we have an excellent opportunity to impact patient status because we have the patient, the physician, and the chart all in the same place at the same time. We learned the (sometimes significant) differences between inpatient and outpatient payment for our procedures. We then shared this information with our physicians and worked with them to develop easier ways for them to remember and document status changes. Adding a reminder and the opportunity to change status to our progress notes or physician orders was quite helpful. By checking for documentation regarding status before the patient leaves our area, we have had a large impact on improving reimbursement for cath lab procedures. Opportunity #2 - Alerting Key Departments to Changes Unfortunately, hospital departments such as Admitting, the Billing Office, Case Management, and Coding deal with the entire patient population and the numerous changes that occur constantly with all patients. Fortunately, we in the cardiology department don’t have to deal with all of these changes since we specialize in treating patients within a fairly narrow scope of practice. So when we become aware of changes that will be coming up, we let people know. When something changes within our world, we get the word out! We use methods such as email, voice mail, and meetings to notify key departments about changes occurring within cardiology that may affect their processes. Recent examples range from clinical issues such as the utilization of new devices and new types of procedures being performed, to payer issues like ICD recalls and CMS-mandated changes in ICD insertion criteria. These changes can have effects on Coding, Billing, Admitting, and documentation (Case Management). We attend conferences, network with each other, read trade magazines, receive emails, and speak with vendors all of which give us access to important information that we need to share. Communicating these vital bits of information with affected departments can prevent large losses in reimbursement from occurring, generally a direct result of a lack of knowledge of our specialty area. These departments are dealing with an overwhelming influx of data related to many different service lines, everything from ortho-neuro to oncology, to women and children, and so on. Cardiology doesn’t even hit their radar screens, quite frankly. We make it our job to be sure that it does. Opportunity #3 - Documentation Although we dealt with documentation issues related to medical necessity in the 2001 article [using our Witt Biomedical system (Melbourne, FL) to collect strategic bits of data, pull them together in one place and have the physician sign it], we have found that medical necessity is just one piece of the documentation pie. From the timeliness of documentation, which affects so many aspects of patient accounts, to the documentation of certain criteria required by payers such as CMS, to the wording of diagnoses so that the coders can understand them and code them properly, documentation is a huge issue that we continue to tackle. Critical to this issue is working closely with your physicians. Educating them as to your documentation needs, and then listening to them and developing methods to make good documentation easier for them to accomplish, is vital. When we ask our physicians to make a change in their documentation, our next question involves something like And how can we make that easy for you to do? Sometimes it involves having techs or nurses capture data which a physician can then review and sign off on. Other times it involves pre-printing criteria choices onto a post-procedure progress note. Then physicians are both reminded to document the criteria as well as provided with a painless method to document long, complicated criteria choices (making a check mark as opposed to writing the criteria out longhand). Figure 2 shows an example of our implantable cardiac defibrillator (ICD) indication progress note, placed on the chart of every patient who receives an ICD at our facility. As CMS required documentation of very specific criteria for implants related to primary prevention after January 27, 2005, we felt that this was an excellent opportunity to help clarify the confusing insertion criteria for all ICD implants. The ICD progress note is a result of that initiative. Auditing Payments -Opportunity #4 Although most facilities audit payment information at a global level, the cath lab requested and received access to financial accounts information that is usually not available to clinical departments. In this way, we can actually see the results of our personal efforts. As we mentioned in the first article, we assume that we did the procedure, we charged correctly for it, we documented everything correctly so we got paid correctly, right? Wrong, as we found out! We are now able to see payment information and investigate areas with low or no-payment of cardiology accounts. As a result, we have been able to make changes in processes that affect reimbursement. One example involved initial ICD implants being done routinely as outpatients with very low or no payment for certain payers. When we began to investigate and questioned our managed care department regarding the payments, they responded, We didn’t know that ICD implants were ever done on an outpatient basis! Based on this assumption, outpatient coverage for ICDs was minimal or non-existent for some payers. We were able to work with both the managed care department regarding future contracts and with the case management department to place these patients in inpatient status when appropriate. This resulted in a significant improvement in our ICD implants reimbursement. While growing in new directions and learning more about opportunities to improve revenue and reimbursement every day, we continue to remember the foundation upon which we built our program. The three error reports that were a full-time job are now a fraction of the job, but the errors continue, and we continue to track and trend the three reports. Figure 3 is a graph showing revenue recovered as a result of CCI Edit interventions done over the past year and a half. Beginning years ago with a foundation of culture change and error reduction, Morton Plant has been able to go beyond what was visible on the surface of revenue recovery and reimbursement, and start to deal with those significant issues that are hidden beneath the surface. The beginning was just the tip of the iceberg! Cheryl Morgan can be contacted at Cheryl.Morgan@baycare.org. Morton Plant Hospital’s December 2001 article, (Is Your Cath Lab Seeing Red? Implementing a Revenue Capture Process Into Your CV Program) is available in the archives section of www.cathlabdigest.com.

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