Faulty and errant documentation and coding are driving outpatient reimbursement inefficiencies, costing U.S. healthcare about $54 billion annually. Unaddressed, these costs are increasing alongside outpatient revenue, growing at a year-over-year rate of 9%.
For providers, the primary catalysts for change are an evolving regulatory environment that includes the ongoing transition to value-based care and restrictions, such as Medicare’s Two-Midnight rule. For patients, escalating healthcare costs and the convenience of outpatient care are pushing people away from hospitals.
So, hospitals and health systems are searching for ways to reduce expenses and shore up revenue streams. Some are turning to single-path coding, where the same coder performs facility and professional fee coding in the same workflow. Doing so can positively impact the bottom line.
Pros and Cons of Single Path Coding
Single-path coding https://www.hiacode.com/education/single-path-coding/can reduce demands on overburdened coding resources and improve individual productivity for coders and the HIM department.
The organization benefits from eliminating code discrepancies and enhancing uniformity across both claims, resulting in fewer delays and denials. Single path coding also helps comply with demands for specific data elements by the Agency for Healthcare Research and Quality (AHRQ).
Similarities exist between the facility and professional fee codes, which helps accelerate the return-on-investment from moving to single-path coding. For example, both use ICD-10-CM diagnosis and CPT procedure codes, and National Coverage Determinations/Local Coverage Determinations for medical necessity are similar concepts between facility and professional fee coding.
However, "similar" is not "same." The differences are significant contributors to the challenges of moving to single-path coding. In fact, there are more dissimilarities in codes used by each side than similarities.
- APCs vs. RVUs - The dominant procedure code typically drives a facility's ambulatory payment classifications (APCs). In contrast, professional fee relative value unit (RVU) reimbursements are based on individual procedure codes. Thus, while a facility's final APC is not necessarily impacted if an additional procedure code is overlooked, if the same happens on the professional fee side, the result can be a costly loss of RVUs.
- OPPS - Professional fee reimbursement and Outpatient Prospective Payment System (OPPS) reimbursement are not reimbursed using the same APC package rates.
- Outpatient Code Editor - The Outpatient Code Editor is not used in the professional fee guidelines.
- E/M Levels - Initially developed for professional fee coding based primarily on medical decision-making, the Centers for Medicare and Medicaid Services (CMS) has since allowed each facility to establish its unique internal guidelines to report clinic and emergency department services provided by hospitals.
- Modifiers - Though many modifiers can be used for both facility and professional fee coding, some are dedicated to each side (e.g., modifiers 73 and 74 are used only on the facility side).
Three Pillars For Success
Overcoming the challenges to single-path coding is made magnitudes easier when the transition is based upon three pillars:
- People - the proper staffing, organizational structure, and culture
- Process - identifying vision and goals, conducting formal training, revitalization, establishing policies and procedures
- Technology - customizing systems, process augmentation, and data-driven decision-making
Establishing these pillars begins with assessing processes to identify any workflow changes needed. Next, three stakeholder groups must come together:
- Physician leaders who understand the benefits of single-path coding and its impact on their bottom line are your best advocates for change.
- IT leaders to devise the organized plan necessary to prioritize single-path coding on the IT project list.
- Coding leaders who understand the tangible benefits the department stands to realize from single-path coding, including acquiring new knowledge and experience.
These stakeholders will play an essential role in establishing the three pillars upon which the single-path coding model is constructed.
The Right People
Finding coders with the right experience and skill sets is typically one of the most significant obstacles to transitioning to single-path coding. The first step is conducting a gap analysis of current skills, the findings of which are leveraged to design training programs that address any shortfalls.
Single-path coders should be able to research new procedures competently to understand how they are performed and, subsequently, how they are coded.
Reliability is also a must. Dependable coders who can consistently meet and maintain quality and productivity standards are vital. Close attention to detail enables single-path coders to identify changes that might impact coding before it blossoms into a problem.
A system of audits to monitor quality should be established with KPIs to measure coder success. Typically, a well-performing single-path coding model will drive increased charge capture and RVUs, reduce lag delays resulting in extra cash on hand and additional savings, lower coding denials through consistent coding and compliance alerts, and improve coder productivity.
Defining the Process
A successful single-path strategy is, in many ways, a process improvement model. First, it involves multiple people making decisions around the consolidation of numerous coding processes into one single process managed by one coder – ideally without sacrificing quality and productivity.
Creating an effective single-path workflow is critical for mapping out coding processes to identify where facility and professional fee coding workflows overlap or intersect. In addition, a workflow analysis should be undertaken to understand how coding works with other departments and the impact coding outcomes have on various aspects of operations.
This workflow analysis should pull in the evaluation of coder proficiencies to refine decisions around training to ensure coders can concurrently code facility and professional fees appropriately for the specific organization. This analysis also provides valuable insights into how far the process can be consolidated.
Implementing the Right Technology
The technology pillar can make or break any single-path coding program. Therefore, it is recommended that a partner be engaged that is willing to work as an extension of the project team. Furthermore, any solution should be customizable to the organization’s workflow – one-size-fits-all will never work in a single-path coding model because workflows and processes are unique. In addition, the selected technology should be able to process data regardless of the originating format to accommodate disparate systems.
Finally, a unified coding platform is vital, so coders do not waste time chasing down information in various systems. It should include natural language processing (NLP) and artificial intelligence (AI) capabilities to suggest medically appropriate codes to the coders, report capabilities and dashboards, and provide feedback to the coders and build facility-specific edits.
Single Path Success
For healthcare providers, cost efficiency, accurate coding, and the need for profits, and financial stability continues to be battered on all sides. However, taking an innovative risk to cut costs and improve reimbursements can help stabilize the bottom line.
Single-path coding may be the risk they need to take for organizations that meet the people-process-technology trifecta.
Leigh Poland, RHIA, CCS, is Vice President of AGS Health's Coding Service Line (firstname.lastname@example.org), and Vivek Menon is Director of Customer Success at ezDI Inc., an AGS Health company (email@example.com).