Q&A: Revenue monitoring
Editor's note: This Q&A is included in NAHRI's 2020 State of the Revenue Integrity Industry Report. Click here to read the full report and participate in 2020 Revenue Integrity Week activities.
The following is a question and answer session with Anna Santoro, MBA, CCS, CCS-P, RCC, system director of revenue integrity/CDM at Hartford Healthcare in Newington, Connecticut, on revenue monitoring as reported in NAHRI’s 2020 State of the Revenue Integrity Industry Survey. Santoro is a NAHRI Advisory Board member.
Q. Nearly 20% of respondents use a vendor-built tool integrated with their EHR to identify revenue leaks. What kind of revenue leakage should revenue integrity aim to identify through the use of this technology?
A. Vendor-built tools can help identify revenue leakage in multiple clinical areas. When starting with a new tool, create a plan to address your hospital’s high-dollar or high-volume areas, as well as specific areas of known concern. Focus on one or two areas at first. This will provide a good sense of how to use the tool and allow time to develop and create standard work. Standard work should include root cause resolution and a monitoring process. Create a plan with a list of focus areas based on dollar value, highest volume, or areas of concern so you can map out your objectives. Establish a monitoring process for previously identified and resolved revenue leakage, and be sure to track subsequent issues in those areas.
Q. What guidance do you have for revenue integrity teams looking to reduce revenue leakage in the emergency department (ED)?
A. In the ED, revenue leakage often occurs in the form of missing charges for supplies and bedside procedures. To ensure chargeable supplies are accounted for, work with the hospital supply chain department to develop a list of chargeable supplies used in the ED and link those supply items to the ED chargemaster. Once you have generated a complete list, develop a standard workflow process to capture those charges. As part of your process, enter charges into the billing system for each patient and perform daily reconciliation.
ED practitioners/physicians, consulting physicians, or physicians called from other areas in the hospital can all perform bedside procedures. It is key to have HIM coders thoroughly review the medical record and capture the technical component of those procedures. If coders are entering a CPT® code for bedside procedures, be sure there is an established workflow for linking these codes to the chargemaster.
Q. What guidance do you have for revenue integrity teams looking to reduce revenue leakage related to drug administration?
A. Drug administration revenue leakage is frequently related to the CPT code assignment for the administration. Retrospective coding reviews for CPT code assignment would verify whether the administration codes were assigned correctly. Review the assignment of the administration CPT codes to ensure modifiers are not used to incorrectly bypass National Correct Coding Initiative edits. In addition, review the documentation to ensure the start and stop times are included in the medical record. If times are missing, coders cannot assign the CPT administration codes. Educate clinical teams on appropriate documentation of start and stop times.
Q. What guidance do you have for revenue integrity teams looking to reduce revenue leakage in pharmacy charges?
A. Pharmacy revenue leakage is frequently related to incorrectly assigning drug units on claims. Work with your pharmacy department to verify they have the correct drug HCPCS code descriptions. Focus on the unit descriptions in the HCPCS code descriptor. Review current claims with high-dollar drugs. Calculate the units that should be reported on the claim by verifying the units provided to the patient based on the medical record documentation. If the calculation is correct, that is good news. If the calculation is not correct, there might be an issue with the pharmacy multiplier.
Q. What areas would you recommend facilities look to for revenue leakage after identifying and mitigating all low-hanging fruit?
A. Revenue opportunities may vary from one hospital to the next. The individual department revenue and usage reports can help gauge sudden or gradual declines in the expected average number of services. These declines may indicate there are missing charges or that a procedure requires a different CPT code. Ask the clinical department whether they have performed a new procedure. If the answer is yes, verify that the procedure is set up in the chargemaster and that charges are captured in the billing system.
Each department should perform a daily reconciliation of charges to ensure all patients who received services have been charged. Reviewing charge reconciliation reports can assist in identifying any missing charges.
Also consider reviewing outpatient procedures associated with multiple implants. Ensure all implants used for a procedure are captured and billed on the claim.