Businesses must reduce expenses and increase revenue to maintain growth and a competitive position. The medical field is a business with multiple added issues. Businesses face the expenses of rapidly increasing technology, an aging population, an ever-demanding expectation, and changing payer rules that risk delays, denials, and audit exposure.

While costs must be controlled, cost cutting alone cannot keep a facility open. This will require looking in depth at the income stream. The revenue cycle must not just be protected, but enhanced. Enhancement is best accomplished by providers. Not by relying on patient contacts or procedures, but by optimizing documentation to ensure full reimbursement and prevent denials. 

Was the most accurate ICD-10 code utilized? Did it correctly identify all the resources used for the care provided? Was the claim submitted within an appropriate time frame? Will the providers' documentation support the level of service and procedure fee claimed? Will the facility or provider-after receiving payment-survive future audits, avoid fines, and manage to keep the payment? 

All departments are crucial to a hospital's function and optimal patient outcomes. However, not all departments are revenue generating. Classic revenue-generating departments, for example, may be radiology, cardiology, orthopedics, or outpatient diagnostic services. 

These strongly revenue-generating departments must support the other hospital areas that are not routinely self-supporting, as well as departments that provide non-billable services. It is important to not only optimize the current revenue departments, but also develop new departments that can provide revenue. 

Facilities often do not realize that a non-revenue-generating department can transition to revenue generating. Understandably then, this transition is under-utilized. The long-term potential of failing to make these changes is a daily reimbursement loss. 

The goal in working with hospitals and providers is to implement a process that allows for not only rapid coding of claims, but also ensures claims are accurate and have an improved chance of surviving a future payer audit. This process can improve quality metrics, reduce delays, prevent denials, provide an accurate bill that includes all services rendered, and shift accounts receivable in a favorable direction. 

The first step in creating a process to assist facilities is to identify the problems each individual facility and staff are facing. For example, providers have limited knowledge of coding guidelines. Exposure to ICD-10 and evaluation and management (E/M) levels is brief, limited, and under emphasized. This puts the responsibility for reimbursement in the hands of the coders and requires them to read and audit each claim. Working powerfully against this effort for accuracy, compliance, and maintenance of the revenue cycle is the great pressure coders have to code a high volume of charts per hour. This economic loss is worsened with the frequency of coders and billers often being physically located away from clinical areas (reducing their access to providers for clarifications) or outsourcing of the service.  

The first step in addressing these problems is to look at provider education for compliance. The providers' first goal must be to provide quality care. This quality care commonly follows treatment modalities, or algorithms, called "best practice pathways." Their goal is to ensure each patient is receiving the most up-to-date and most successful treatments. 

However, in order to accurately reflect a diagnosis and treatment, providers must document charts using words and phrases that match coding manuals. This coding and billing documentation wording is ever changing, and likely different than both the wording taught to providers in their training and different from the communication used between providers.

Providers may not need to use these specific words to take good care of the patient, or accurately record what they have done. This is a source of significant provider resistance. However, providers must use these words to be compliant with payers, ensure optimal revenue generation, and receive appropriate credit for quality metrics.

Evaluation and management (E/M) is the system used by payers to turn a physician's cognitive problem solving and diagnostic skill into reimbursement in dollars. The reimbursement amount is determined by the provider's E/M level selection, and the selection level is determined by the documentation. This applies to all patients-office, nursing home, hospital-based patients, as examples. 

Requirements for what must be documented in the note vary based on the level of claim submitted. When using electronic health records (EHRs), there are strict rules for how data must be recorded as well as what data must be recorded. Records that do not pass payer audits are susceptible to losing already received payments, as well as interest, penalties, and fines.

Physicians who dictate procedures must do this in compliance with current procedural terminology (CPT) and healthcare common procedure coding system guidelines (HCPCS).  Documentation that does not meet guidelines gives the payer the opportunity to at least delay payment as more information is requested, or deny payment if information is recorded incorrectly.

Routinely, the CEO/CFO is not aware of the audit risk exposure of their employed physicians and facility fees. This is placed at risk by poor provider documentation. Is medical necessity demonstrated? Was this procedure, imaging, or laboratory test needed? Would the payer agree that the outpatient chart documentation supports the service? Appropriate documentation will answer yes to all of these questions. 

Outpatient ancillary services are a crucial part of a hospital's revenue. To lose any portion of this due to poor provider documentation can be a crippling loss and, perhaps more importantly, an avoidable loss with provider education.

Another common problem is matching the expectations of CFOs to the realities of day-to-day practices. The concept of coding charts at an increased speed is valid. Nothing is as important as revenue cycle management. Without that, doors do not stay open. But coding charts quickly may result in errors or decreased optimization and lead to audit exposure. It does not help the health of a system to have a policy that increases future audit risk. 

This is becoming increasingly worrisome, especially for administrators, as they are being held personally responsible for the facility's compliance errors. With enforcement definitions of "knowingly" being defined as "knew or should have known," the accountability has moved from providers, to coders, and now on to the CFO and by extension the CEO.

The solution rests with team building. The personnel, from provider to coder to biller to C Suite, must all understand they are intertwined. All must buy in and understand the current expectations for documentation and coding. The way to increase the volume of charts that may be coded per hour is to educate the provider about what the coder needs. If the provider can understand the concept of putting what the coder needs where they need it, the speed of claim submissions, and more importantly accurate claim submissions, will increase. 

ICD-10 CM has approximately 70,000 diagnosis codes compared to 14,000 in the prior ICD-9 CM version. HCPCS now has nearly 90,000 codes compared to 4,000 in ICD-9 CM. Strict coding guidelines govern which code to apply, the order the codes are to be sequenced, which extra codes should be added, and if modifiers are appropriate. This requires coders to go through specific and extensive training to understand all of these variables. 

The provider does not need to understand ICD-10 CM at the level of the coder. The providers do, however, need to be aware of the information the coder needs, respond quickly to coder queries, and learn from each interaction. In educating providers on ICD-10 CM, it is important to stress guideline rules rather than the providers' desire to try and memorize "my top ten" diagnosis codes. The concepts of with and without, code also, code first, and code to the highest specificity need to be understood in a more global fashion. Understanding the detail needed by the coder allows the provider to record that information level of detail.

When the provider can begin to understand what the coder needs to see in the documentation, the provider can begin to record that level of documentation. The coder then can much more rapidly select the most specific, most accurate, and therefore the most defensible code. The proper code survives an audit. The provider now has started that first step in becoming part of the solution. 

Provider buy in is crucial to success. To develop provider buy in, they must be shown the "what is in it for me" concept. It is very helpful to equate chart audit passes and chart audit fails with dollars won and dollars lost. This includes not just immediate economic loss but the risk of inviting further scrutiny.

Coders are too often located physically away from the providers-the people with whom they need to have the most interaction. This simple fact of distance reduces communication, reduces code selection accuracy, and leads to coders having the perception they are not integral to the process.  This is an issue that must be resolved.  

The tremendous specificity of ICD-10 is such that coders will need to query providers.  As providers learn more, they will have more detailed questions. They are far more likely to ask the question, and subsequently learn from the answer, when they can quickly have face-to-face access to coders. The provider must understand the coder is his/her greatest ally. Relationships must be established.

For providers to be part of the solution, they must want to be part of the solution. To accomplish this, they must understand the problem, understand that improved effort is needed, and understand the help available to them. Understanding their personal economic loss and showing the economic loss that documentation errors place on the hospital is integral to accomplishing this goal. 

Providers must recognize the economic realities of documentation. Recognize that they influence their own, their partner's, and their hospital's solvency.

Now to the importance of queries. Sometimes, it is overlooked that queries must be submitted to the providers in an appropriate and non-leading form. But there is an even greater problem: the provider's absence of understanding the importance of the query itself.

This is most evident in the queries' responses, or routinely, lack of responses.  When the queries are not answered, the needed information is not received. Often, they are answered, but the answer still does not address the issue in question. This results in the coder then making a "best guess," which is unlikely to be the most appropriate selection or an audit defensible selection. Further, it increases coder frustration and reduces the likelihood of sending the next needed query.

When a provider receives a query, it is in their own best interest not just to respond, but to actually meet with the coder. They can then understand the query need, learn how it improves claim accuracy, reduces delays and denials, and improves a given provider's quality metrics. Provider realization that the query is a positive toward their income and metric evaluations will improve the provider/coding/billing success moving forward. This development of a symbiotic relationship may be the single most important benefit for the hospital and the providers. 

When providers have reached the understanding of the coders' value to the individual provider, quality accelerates. Coders are happy to teach and be recognized for the value and expertise they bring. The successful provider will understand the need to develop documentation that is compliant with the current rules and regulations of healthcare and reimbursement. An understanding that their personal economic and metric rewards are a function of this compliance is a motivating feature.

The only way to provide communities with healthcare and jobs is to keep facility doors open. By educating providers and support staff, leaders can build increased compliance and improve both economic and healthcare metrics. 

Finally, the importance of team building cannot be over-emphasized. Coders have to be recognized by providers as integral to the overall health of the system. The value of a compliance consultant is not just to show areas at risk, but to also offer a potential plan for the resolution of these risk areas. The team of providers plus coders will allow for quick clarifications and subsequently the most appropriate billing to be submitted. This will improve on-time payment, enhance the revenue cycle, and help protect against future audits.