NAHRI leadership and revenue integrity experts share news, analysis, and insight during quarterly call

Wednesday, November 14, 2018

NAHRI members tuned in for expert analysis of new and upcoming changes including inpatient admission order requirements, appropriate use criteria (AUC), and learned how to apply for the association’s new credential during NAHRI’s October 30 quarterly members-only call.

The call opened with announcements about some of NAHRI’s most anticipated initiatives. NAHRI Director Jaclyn Fitzgerald announced that applications to sit for the Certified in Healthcare Revenue Integrity (CHRI) exam are now open. Those interested in applying can review the complete list of requirement and prerequisites on the NAHRI Certification website.  The CHRI credential can help new and veteran revenue integrity professionals demonstrate knowledge of revenue integrity core competencies. Professionals who earn the CHRI credential have proven their proficiency in rules and regulations, compliance, revenue management, and internal reporting strategies.

Other NAHRI news included announcements that members may apply for positions on the NAHRI Advisory Board and committees including the Professional Advocacy Committee, the 2019 Conference Committee, the Forms and Tools Committee, and the Networking Committee. Interested members can visit the NAHRI website for more information and can complete the application online through December 12.

After the announcements, four NAHRI Advisory Board members offered the following tips and analysis on current and upcoming revenue integrity concerns:

  • AUCs for advanced diagnostic imaging. Although AUCs for advanced diagnostic imaging aren’t new, many organizations, particularly hospitals, haven’t taken the time to review and prepare for implementation in 2020. Denise Williams, COC, senior vice president of the revenue integrity division and compliance auditor at Revant Solutions in Trussville, Alabama, looked at the current progress of the program, its implications, and offered tips on how organizations can prepare to meet reporting requirements. At this time, information on AUCs for advanced diagnostic imaging can be found in the CY 2019 Medicare Physician Fee Schedule (MPFS) proposed rule, and per the proposed rule would apply to hospital outpatient departments including emergency departments. However, Williams pointed out that the program specifically excludes services ordered for beneficiaries with emergency medical conditions. This would appear to be contradictory. In addition, although mandatory reporting will begin January 1, 2020, CMS stated that during the first part of 2020 it will pay claims even if the wrong AUC is reported. The proposed rule does not define the precise duration of that grace period. Williams also cautioned against putting off preparing to report AUCs for advanced diagnostic imaging. Reviewing processes and devising and implementing necessary changes can be time-consuming, and hospitals would do best to start early. “It would be wise to start taking a look at this from whatever aspect of the process you’ll be involved with,” Williams said.
  • Commenting on proposed rules. Over the past several months, NAHRI members and revenue integrity experts alike have called for revenue integrity professionals to take a leading role in submitting comments on proposed rules. Diane G. Weiss, CPC, CPB, CCP, discussed the importance of submitting comments and offered tips and strategies for breaking complex and lengthy proposed rules into manageable sections. Most hospitals find success by taking a team approach to analyzing and formulating responses to proposed rules, Weiss said. Key staff members from revenue cycle and revenue integrity can be assigned specific sections of the proposed rule, ideally those that align with their current role, professional background, and expertise. These staff members can create a list of pros and cons and send draft comments to financial or revenue cycle executives. Those executives then create and submit a comment on behalf of the organization. That review process also benefits the organization by allowing it to analyze the implications of proposed changes and forecast the potential impact on the organization, Weiss pointed out. It’s critical that organizations and revenue integrity professionals use CMS’ proposed rule comment period to provide the agency with specific feedback and alternative proposals as the agency may revise the final rule based on comments. “Commenting on proposed changes affords us a tremendous opportunity to shape the future of healthcare,” Weiss said.
  • Managing annual chargemaster updates. The chargemaster is one of the core revenue integrity documents, and ensuring it is updated is a critical revenue integrity function. Anna Santoro, MBA, CCS, CCS-P, RCC, revenue integrity system director at Hartford Healthcare in Newington, Connecticut, discussed guidelines for annual chargemaster updates and how to develop a process for chargemaster updates. The first step is identifying Current Procedural Terminology (CPT®)/Healthcare Common Procedure Coding System (HCPCS) changes. The best way to ensure you’ve noted all code changes is by comparing the new version of the CPT Manual to the previous year’s, Santoro said. Also review the CPT/HCPCS crosswalk to ensure that all changes are correctly mapped. Don’t forget about third party applications. If these are not updated, it could affect orders listings, preference lists, or encounter forms. Revenue integrity should also create a process to address pricing updates with the finance and budget departments, Santoro said. And finally, ensure that staff are aware of the chargemaster updates and the code updates. “The more people who know about the code changes, the better off your organization will be with ensuring correct CPT/HCPCS code assignments for services rendered,” she said.
  • Inpatient admission order requirements. The CY 2019 inpatient prospective payment system (IPPS) eased inpatient admission order requirements but still left several questions unresolved from the proposed rule. Ronald Hirsch, MD, FACP, CHCQM, vice president of R1 RCM in Chicago discussed CMS’ reasoning in the final rule and offered suggestions and interpretations on the application of the new requirements. Per the IPPS final rule, a written inpatient admission order does not need to be present in the medical record as a condition of Medicare Part A payment. However, CMS also stated that a patient cannot be considered an inpatient without a written inpatient admission order. To understand what this might mean in practice, it’s critical to understand CMS’ reasoning, Hirsch said. CMS appears to have been addressing situations in which certain common technical discrepancies such as the authenticating signature not being obtained until after discharge were causing otherwise medically necessary claims to be denied. Hirsch discussed several strategies for addressing inpatient admission order errors and stressed the need for hospitals to continue to monitor and address these errors and discrepancies. Another key aspect is that CMS supported the change by citing Chapter 1, section 10.2 of the Medicare Beneficiary Policy Manual. This states that in “extremely rare circumstances, the order to admit may be missing or defective” although the intent, decision, and recommendation of the admitting physician is clearly documented and that MACs should use their discretion to determine whether the documentation is sufficient. “They don’t tell us exactly what ‘extremely rare’ is,” Hirsch said. “That’s something you have to define.”

NAHRI members can download a recording of the October 30 call and the presentation slides on the Resources page of the NAHRI website and can register for the next quarterly call scheduled for Tuesday, January 29, 2019, at 1 p.m. Eastern. If you are a NAHRI member and would like to present during an upcoming quarterly call, please contact Associate Editor Heidi Samuelson at