Revenue integrity tips for 2021

Wednesday, April 14, 2021

Much like other areas of healthcare, the world of revenue integrity has undergone quite a bit of change over the past year.

On the March 11 episode of The Revenue Integrity Show: a NAHRI Podcast, Kay Larsen, CRCR, CHRI, revenue integrity specialist at Adventist Health Glendale in Glendale, California, and Sarah L Goodman, MBA, CHCAF, COC, CHRI, CCP, FCS, president/CEO of SLG, Inc., in Raleigh, North Carolina, teamed up to offer revenue integrity tips they wish they knew a year ago.

The podcast, which was moderated by NAHRI Director Jaclyn Fitzgerald, CHRI, covered a wide range of topics related to revenue integrity in the era of the novel coronavirus (COVID-19). Larsen and Goodman offered thoughts on the following topics:

Revenue codes for COVID-19 vaccine administration

As Larsen pointed out, changes occurred at a fast and furious rate at the outset of the COVID-19 pandemic, and revenue integrity professionals had to adapt on the fly.

“I’m sure I missed some things because now I’m starting to get some denials on codes,” Larsen said.

Some of the initial denials were related to vaccine administration and monoclonal antibodies. Through trial and error, Larsen said she has learned the best revenue codes for these procedures. Many hospitals believed these procedures were provided on inpatients, and they were setting them up using a 0250 revenue code that would typically be used on an inpatient versus the 0636 code used for outpatient, according to Goodman. Larsen’s facility found itself in this situation.

“Vaccine administration was triggering over to the vaccine claim, but then we got an error because we didn’t have anything to go with it,” Larsen explained. “It was just a matter of contacting our corporate office and having them update the revenue code so that both the administration and the drug can get over on the same claim.”

Room charge revenue code

Organizations experienced some difficulty with reimbursements for room and board, including the 0164 for sterile environment, Goodman said.

During a COVID-19 surge in December, Larsen’s organization made the decision to use the isolation room charge for any COVID-19 patients. But some contracts indicated that the 0164 revenue code would be mapped to the medical/surgical rate, creating a problem for the organization.

“If we changed the tele room charge to isolation, we were actually losing our tele reimbursement fee and getting a med/surg,” Larsen said.

The idea was that the isolation room charge, which is a higher price than the tele charge, more accurately reflects the costs that are involved in providing isolation care. But this didn’t translate to reimbursement all the way down to the claim level, according to Larsen.

Larsen passed along an important lesson learned.

“When you have your clinical staff making decisions like this, you really need to invite yourself to the party if you’re not already included,” Larsen said. “And make sure that maybe someone from even Patient Financial Services is involved in that meeting too.”

Keeping reimbursement information up to date

When reporting drugs, organizations should make sure they have the right units of the base dose reported.

One example among the HCPCS J-codes is J3399, a newer code that has a payment rate on Addendum B of more than $2 million, said Goodman.

“You really want to make sure you are reporting that with the correct units and that you’re pricing it appropriately,” Goodman said. “If there are any NCCI edits that you are encountering, look in the manual. The manual is updated every year and it will show you anything that is new in a red font.”

Larsen added that she frequently uses Addendum B for outpatient surgeries, putting a particular focus on status indicator.

“It’s exciting to see when you pull up CPT® codes, ‘Yes, Medicare will pay it,’ but then you have to look at the status indicator,” said Larsen.

The status indicator will answer key questions, such as whether the payments are composite payments and whether the organization will receive full or partial reimbursement.

For more revenue integrity tips, check out the recording of the March 11 podcast on the NAHRI site or iTunes, Spotify, Google Play, or SoundCloud.