Updated on: November 28, 2016

Ensuring That Outpatient Coders’ Expertise is Maintained and Effectively Used

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Original story posted on: October 17, 2016
I chose the titular subject for this article because many of us have been focusing on ICD-10-CM and PCS – and while CM is used by both inpatient and outpatient coders, we may have lost sight of CPT and HCPCS.

CPT® and HCPCS education is as important as ICD-10, especially considering the continuous shift of patient care to the outpatient environment. The X modifiers provide options in lieu of modifier -59, and the need to use G-codes for Medicare can lead to fewer denials. The key question is this: are we providing the same intensity of education for our outpatient coders in the CPT arena as we are for our inpatient coders with ICD-10?

One of our First Class Solutions senior consultants, Bill Remmich, continues to observe some rather significant APC changes happening while we’ve been focusing on ICD-10’s impact on DRGs. For example, take the case where the procedure is:

  • RT distal claviclectomy, decompression, rotator cuff repair and biceps tenodesis.
  • 2015: three APCs, 42x3, reimbursing approximately $8,058.81
  • 2016: one APC, 5123x1, reimbursing approximately $4,778.27, paying a higher rate on one bundled APC.
  • Net Loss:    $3,280.54
This is not the only scenario that changed from 2015 to 2016, and I bet our outpatient coders are probably seeing these changes as they perform their grouping.

Health information management (HIM) leaders and coding professionals should be collecting information about the impact of these changes and forecasting the financial impact for the CFO.  Otherwise, if a revenue decline is noted by the CFO, the first thought will be that it was the result of erroneous coding. For those football fans out there, you know it’s far better to be on offense than on defense.

HIM is seeing its space erode. It is time for HIM representatives to plant themselves in the center of the revenue cycle. One way to do that is to take over the charge description master.  Now, before you roll your eyes, recognize that the charge description master drives all service charges and coding drives all reimbursement methods. The CDM has tentacles into every patient care department and touches every department that contributes to the health record.

According to registered nurse Cathy Meeter, this is the backbone of reimbursement, providing many of the necessary data elements for compliant claims submission.  So, why shouldn’t one department manage both sources of revenue flows? Doing so would eliminate lost reimbursement or erroneous claims, because procedures that should be coded by coders are hard-coded in the chargemaster. It would also catch those new services that appear in our records but were not added to the CDM. HIM can be the primary source of identifying lost revenue opportunities and lead the “cash is king” initiative for any organization.

Our outpatient coders are perfectly positioned to take over the chargemaster. Now, I wouldn’t convert all our outpatient coders to CDM coordinators. But there are probably one or two outpatient coders on your team who have the propensity to expand their skills in this area and are interested in working closer with the folks in finance to accurately price services. Coders understand the intensity of services and resources involved in different procedures. They can guide finance to “clinically price” a service rather than use a standardized formula based solely on costs. Consider how coders filling this role could elevate the perception of health information management and coders not just within the organization, but with providers and the public. 

The coder/CDM coordinator will have full access to, and know the content of, the various Medicare transmittals when they are published. How beneficial will this knowledge base be for the other members of your coding team? Knowing code changes and Medicare requirements before the encoder is updated will benefit the organization by reducing dirty claims, rejections, and denials.

Are there other benefits for coders managing the CDM? Yes – who is better than a coder at using descriptions for codes that the public will understand? Creating a patient-friendly description helps patients understand their charges. It also may open an opportunity for the HIM department to be the source of transparency pricing for the public. Often this role is fulfilled by patient access. Which team has a more thorough understanding of clinical procedures and the ability to pronounce them as well? 

Another benefit is the coder’s ability to spot errors. Striving for data integrity is one trait health information professionals often share. Our coders see errors daily, in documentation, in charges posted or not posted to claims, and in misinterpreted results. Their clinical expertise is critical in a CDM role.

Outpatient coders can make valuable contributions to any organization. To be recognized, they must be up-to-date with CPT and HCPCS codes and modifiers, understand how coding variations may affect reimbursement, and have the moxie to nudge their way into revenue cycle leadership.

Go for it!
Disclaimer: Every reasonable effort was made to ensure the accuracy of this information at the time it was published. However, due to the nature of industry changes over time we cannot guarantee its validity after the year it was published.
Rose T. Dunn, MBA, RHIA, CPA, FACHE, FHFMA, CHPS, AHIMA-approved ICD-10-CM/PCS Trainer

Rose T. Dunn, MBA, RHIA, CPA, FACHE, FHFMA, CHPS, is a past president of the American Health Information Management Association (AHIMA) and recipient of AHIMA’s distinguished member and legacy awards. She is chief operating officer of First Class Solutions, Inc., a healthcare consulting firm based in St. Louis, Mo. First Class Solutions, Inc. assists healthcare organizations with operational challenges in HIM, physician office documentation and coding, and other revenue cycle functions.

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