Correct procedure coding is a primary, and pivotal, activity among providers and payors alike. Undercoded claims leave money on the table, while overcoded claims leave the practice exposed to financial risks, including potential accusations of fraud. If a practice spends too much time on coding, reporting, reviewing, scheduling, code approval, and amending reports, the practice will suffer as turnaround times increase and staffing expenses soar.
What if you knew, though, that more than 99% of your practice’s claims were correctly coded? Would your practice bring in more money? Would you sleep better at night, knowing that you were not at risk for repayment and/or fraud accusations? How can correct coding be achieved while improving, not harming your practice or patient care? All of these questions provide a framework for establishing a simple, yet necessary, system for ongoing audit and review of your coding practices.
About a year ago, I introduced myself to ImagingBiz.com’s readers as Inland Imaging’s new chief reimbursement officer (CRO). As the company’s CRO, I am responsible for maximizing the revenue delivery of our organization by implementing and managing billing and contract practices that accelerate and enhance billing services.
In that article, I discussed Inland Imaging’s plans to improve coding through audits, education, and operational process improvements. What follows is an update on what we’ve done so far, challenges that we overcame, progress that we have made, and our plans for continued improvement.
The Audit Process
If your practice is like most, codes included on the claim are generated in one or more of the following ways: by importing codes from the hospital and/or imaging center; by professional coders manually coding from the provider’s report; and, increasingly, by the use of a natural language processor to abstract from the provider’s report with coder oversight.
Inland Imaging uses each of these three methods, depending on the practice site, as a result of its service delivery through hospitals, owned imaging centers, and third-party management agreements. We began by randomly selecting claims from each modality, and we then audited the claim from the starting point to the closure of the claim (essentially, A to Z). Recognizing that there are several potential trouble points, we developed a tool within which we recorded the variances
- between what procedure was ordered (both initial and revised) and what procedure was performed (as documented within the RIS through technologist notes, nursing notes, and so forth);
- between what procedure was performed and what was substantiated in the radiologist’s report; and
- between what procedure and outcome were substantiated by the radiologist’s report and what was actually billed.
Given the manual process required for this level of research, we necessarily limited our audit sample to 200 to 300 randomly selected claims annually per modality, which for us was between 0.5% and 1% of the annual total for CT and MRI.
What We Learned
So far, we have completed a comprehensive review of both CT and MRI through the audit process. Because corporate compliance is of principal importance, we initially focused on the differences between the coding substantiated by the physician’s report and the coding ultimately submitted to the payor. Key learning: We found that in using only the radiologist’s report to substantiate coding, we invariably ignored the balance of the medical record. Thus, for every two claims that were overcoded, three were undercoded.
Digging a little deeper, we discovered that the coding submitted to payors was actually closer to what was actually performed, and that that the technologists in the core were better at reflecting the level of service performed than the doctors were in getting all the necessary information into the report. Key learning: Use the expertise of the technical team to identify and correct miscoding initially.
Often, the radiologist’s report did not address all components necessary to substantiate the claim. The most common errors included the failure to mention the use of contrast in the report (the need for or administration thereof), and/or failing to document all views that substantiate a complete versus limited examination. Key learning: Do not rely solely on the outbound report as the basis for proper coding.
Faced with the knowledge that our billed codes do not always sync with the level of