Sustainable solutions: Collaborating with clinical departments on root cause solutions to coding edits

Wednesday, August 25, 2021

It’s a struggle most revenue integrity professionals can relate to. A root cause analysis of a persistent coding edit points back to problems in the clinical department. However, the clinical department’s leader believes the responsibility for creating and implementing a solution lies with the coding department. Revenue integrity is caught attempting to mediate the stalemate while claim edits continue to pile up. It’s sometimes tempting to throw in the towel and settle on a less effective and more resource intensive back-end solution but that’s not sustainable long-term.


Bringing clinical departments on board isn’t a pipe dream. By listening to clinical departments’ concerns, minimizing disruption, and emphasizing the interconnectedness of hospital functions, revenue integrity can mediate practical solutions, according to Denise Williams, COC, CHRI, senior vice president of revenue integrity solutions at REVANT Solutions in Raleigh, North Carolina. During the webinar “Clearing Up NCCI and MUEs: Best Practices to Resolve Edits and Protect Revenue” Williams shared strategies for conducting root cause analysis and resolution, identifying departments that should be involved, and delegating specific responsibilities.


“What I have found to be successful is talking to the clinical department and telling them they are an integral part of how services are rendered and billed, and they do have an investment in how this process works,” Williams said. “The hospital is a team, and we can no longer think about ‘my department’.”


Hospital staff are accustomed to thinking of each department as discrete, siloed entities. For example, the oncology department, the emergency department (ED), and the radiology department are all separate areas offering different services. Nevertheless, these departments are part of the same entity and what each does, or doesn’t do, affects the others, whether this is from a patient experience perspective or a billing and claims perspective, Williams explained.


Revenue integrity’s challenge is to bring together stakeholders from clinical departments to learn about their processes and for both parties to understand how they affect each other, she added.


For example, a root cause analysis discovers that some claims are hitting an edit due to charging practices in the radiology and surgery departments. Although a particular line item can’t be charged separately by the radiology department due to the CPT code, that department is reluctant to alter their practices because it will negatively affect their ability to meet a productivity criterion. After reviewing the processes, systems, and benchmarks, the revenue integrity department discovers it isn’t necessary for radiology to bill the CPT® code to meet the criterion—simply charging the line item or completing the line item in the radiology system may be sufficient.


In this scenario, surgery, radiology, patient financial services, revenue integrity, cost reporting, and any other stakeholders involved should meet to discuss potential solutions and consider how they would be implemented, Williams said. The most common solution in this situation is to have the surgery department charge for an entire service that involves both surgery and radiology. To accomplish this, the radiology resources cost needs to be moved behind the scenes to the surgery department, she explained. Another option is to create a line item in the radiology department’s chargemaster, assign it revenue code 360, and don’t attach a CPT code. With the hospital’s claims creation process, the radiology line item combines into the surgery line item and all costs are captured. Either option would be acceptable and in compliance with Medicare’s requirements, she added.


“All of the charges are there and compliant for billing, and there is a line item from radiology that reflects they did a procedure, so they get credit for productivity. There’s nothing that tells you that you can’t do that,” Williams said. “Medicare doesn’t tell you how to structure your charges. All Medicare tells you is that all patients must be charged the same but when the codes combine on the claim, the codes need to be reported correctly.”


It may also be worth reconsidering how the radiology department reports productivity, Williams said. Although many departments’ productivity is driven by their chargemaster, that approach no longer works well because of coding requirements and how coding edits are structured. For the radiology department, for example, reports pulled from the radiology system provide productivity data without relying on the chargemaster.


Whichever solution is arrived at, the clinical departments must remain engaged, Williams said. Setting and communicating clear expectations and sticking to a set meeting schedule will keep the process organized and ensure that clinical departments don’t feel caught off guard. Avoid multiple meetings a week to discuss individual edits—a longer meeting once a week, for example, will actually save time.


Meetings should be scheduled around the clinical departments’ representatives’ availability. Mid-morning and mid-afternoon are typically not good times because that’s when most clinical departments are busiest, she pointed out.


It’s also helpful to ask the department manager whether anyone on their team is interested in volunteering, Williams said.


“There’s most likely somebody in that clinical department for whom this would be right down their alley,” she said. “They would be willing to be the department representative to help work on a solution, and then take the information back to the department.”


When working with clinical departments on root cause solutions, emphasize that it’s ultimately about making their lives easier, Williams recommended. Addressing root causes in a comprehensive, collaborative way means that clinical staff will ultimately need to spend less time on administrative tasks, easing the chance that these tasks will take away from time spent on patient care.