Streamlining ED Coding & Charging
By Cheryl Bowling, RHIT, CCS, CHC
For The Record
Vol. 18 No. 1 P. 20

With help from an outsourcing partner, an Ohio hospital was able to energize its revenue cycle and achieve cost savings.

The contribution of the emergency department (ED) to hospital revenue generation is steadily increasing. According to a recent report from the Centers for Disease Control and Prevention, ED visits have reached an all-time high—113.9 million in 2003, up from 90.3 million in 1993. This comes despite the declining number of hospital EDs, which have fallen approximately 14% during the same time.

Historically, EDs have lost an average of $84 for each patient treated and discharged. However, patients admitted to the hospital from the ED generate an average profit of $1,220, according to the California HealthCare Foundation. With EDs now accounting for more than 40% of all hospital admissions and approximately 20% of net profits, the ability to capture all appropriate revenue is critical. Thus, overcoming the unique challenges presented by the coding and charging of ED patient records is an issue that demands attention.

Dealing With the Issue
Exacerbating the problem is the shortage of experienced coders, which some estimate to be as high as 30% nationwide. Furthermore, the situation is not expected to improve. The Bureau of Labor Statistics estimates that U.S. hospitals will need 97,000 new medical record and medical health technicians by 2010 just to replace those who leave the field.

This heightened demand for emergency services and shortage of experienced coders (combined with increasingly complex compliance requirements and the fast-paced environment of the ED) create a situation that is ripe for miscoded or uncoded charges. This can ultimately result in delayed or lost revenues for hospitals and, in some cases, hefty fines.

One solution has been the use of outsourced vendors to assist with coding needs. However, the problem in the ED goes beyond the need for increased staffing, reaching into the underlying charge capture process as well as coding. To address these special challenges presented by ED coding and charging, one hospital looked to an innovative outsourcing model that utilizes outsourced, remote coders and streamlines the coding and charging functions into one seamless process. The outcome was a significant reduction of backlog, more accurate coding and charging, and a speedier turnaround time between the patient visit and delivery of the completed chart to the billing department for claims submission.

Case Study: Doctors Hospital
Located in Columbus, Ohio, Doctors Hospital is one of five hospitals that make up the not-for-profit OhioHealth organization. The 200-bed, acute care hospital operates one of central Ohio’s busiest EDs, averaging 70,000 patient visits per year.

With such a heavy volume of emergency service activity, the hospital is faced with issues confronting all acute care and specialty hospitals—accelerating and maximizing revenue cycle performance.

Previously, the hospital’s ED charts, which averaged 200 per day, were sent out for coding and charging, then returned to the facility for discharge and disposition before submission to the billing department. That process took approximately 18 days.

When the existing outsourcing contract was due to expire, the decision was made to bring ED chart processing in house, but to do so under a new model, developed with a staffing firm, that would utilize remote coders and combine charge entry, coding, abstracting, and discharge disposition into one step. Desired outcomes for this model were the following:

• streamline and combine processes;

• speed turnaround time;

• improve accuracy and reduce the number of rejected or returned claims;

• “navigate” through three existing IT systems;

• staff the project with certified coders and train them in the charge process;

• align Doctors Hospital with the Evaluation & Management (E&M) scorecard being used by OhioHealth’s other facilities; and

• address the shortage of qualified coders—annual openings in Ohio average more than 340 and demand is expected to grow each year.

Managing the Process
The new program called for patient charts to be scanned into a queue and assigned to one of six coders, each an HIM-certified professional, based across the country.

Coders access the hospital’s systems and charge out all services, including assigning the E&M level and capturing any nursing services, injections/infusions, and treatments that are separately billable. They also complete the appropriate discharge disposition in the billing system, including type of visit and source codes, followed by abstracting and coding. The completed charts are then sent directly to the billing department for claims processing. The project is managed by an agency project manager, who handles quality assurance and ongoing coder training and acts as a liaison between the hospital and coders.

Implementing the new model required the support and cooperation of a number of hospital departments—in particular, information systems (IS), billing compliance, and corporate coding—to establish the components necessary to implement the project within a three-month time frame. These components included providing secure access to the hospital’s IT applications, developing policies and procedures, training coders, developing ongoing communications vehicles, and establishing performance measures. Details on each component follow.

Secure Access
Virtual private networks (VPNs) were installed to provide coders direct, secure access as well as to record usage and track access and time. Working with the contracted staffing firm, the hospital’s IS department rewrote existing system menus to provide coders access to three separate systems:

• eWebHealth from ChartOne, Inc., for scanning, chart storage, and visualization;

• OhioHealth Results Browser, the hospital’s clinical information system that provides access to lab results, radiology, cardiology, and transcription; and

• McKessonHBOC, Doctors’ MPI (master patient index), billing/charge entry, coding, and abstracting system.

HIPAA compliance was also a key consideration because records would be moving electronically to outsourced, remote coders and back to the facility. By using eWeb Health, coders were able to view the image of a scanned chart but could not print or permanently download the record to their personal systems. In fact, once the completed record was uploaded back to the facility, it was deleted from the coder’s system. And, as an added measure of security, the encrypted image self-deletes after 30 days.

Policies, Procedures, and Training
The next critical elements, produced in an integrated manner, were the development of necessary policies and procedures and subsequent incorporation into a training manual for coders.

OhioHealth’s billing compliance department, in conjunction with HIM, worked from the scorecard being used by other OhioHealth facilities. Doctors’ unique charge description master (CDM) was added and appropriate sections of the HIM policy and procedures were incorporated. For quick identification, the manual color coded sections on supplies; infusions, transfusions, and injections; labs; ancillary; ED visits; and orthopedic visits and procedures.

Once the training manual was established, the billing compliance and HIM departments developed and conducted a comprehensive, two-week, on-site training program for coders that not only taught them how to maneuver through the various applications, but also familiarized them with the hospital’s charting system and the mechanics of entering charges and making corrections when necessary.

The latter was a critical step. In many cases, even the most experienced credentialed coders were not familiar with the CDM and how the charge, revenue, and CPT codes map to it to populate the record for billing. Training was also provided on the discharge disposition process—another area unfamiliar to many coders.

The training process identified areas in which changes were needed to ensure regulatory compliance, as well as new charges that needed to be created. Payor-specific issues, such as Ohio’s Medicaid requirement for specific modifiers, were also part of the training to ensure coders were educated on when and how they should be applied to produce a clean bill.

Communications
Making the remote coding and charging program work efficiently required close communications. The relationship among the agency’s project manager, hospital representatives, and coders was key to the program’s success.

Once training had been completed and remote coding initiated, the project manager scheduled weekly meetings with the HIM operations manager and the corporate coding manager to discuss the previous week’s results. Discussion typically centers on results of the Hatfield Report, a compendium of all relevant information, including identification of the status of all accounts, reconciliation of any outstanding accounts, missing documentations and records, and charge issues.

The weekly meetings also serve as a forum for the project manager to share general concerns and questions raised by the remote coders—with whom she conducts monthly meetings.

Performance Expectations
To ensure that the new system was meeting its primary objectives of accelerating turnaround times, improving overall accuracy, and reducing rejected or returned claims, minimum performance standards of 50 charts per coder per day with a 95% accuracy rate were established. Again, the project manager played a critical role, performing regular quality assurance audits of the coding team’s performance.

On average, the remote coders processed between 50 and 80 charts daily and exceeded the 95% accuracy rate. However, in rare instances in which performance slipped below expectations, the project manager was able to quickly identify the problem area and follow up with additional training for the coder, carefully monitoring performance until it again achieved the proper level of accuracy.

Outcomes and Keys to Success
Within several months, coders were meeting all performance standards and the billing cycle was reduced from 18 days to four. As a result, the program accelerated the revenue cycle of the ED and positively impacted the hospital’s bottom line.

The new ED coding and charging model offered numerous significant advantages, including the following:

• a streamlined process that eliminated one or more steps between the patient’s visit and final claim submission;

• improved accuracy that led to cleaner billings and a reduction in the number of failed or rejected claims;

• faster charge capture made possible by the ability to work directly in the charge system; and

• access to experienced, certified coders in spite of the ongoing shortage.

Final Considerations
Recognizing the rising demand for emergency services and the significant impact the ED has on a hospital’s financial performance, there is a growing need for innovative coding and charge capture programs. The model established at Doctors Hospital demonstrates that integrated ED coding and charge programs can help enhance financial revenue cycle performance, lower costs, improve accuracy, and reduce the number of failed/rejected claims—while also overcoming the issues posed by the shortage of certified coders.

Using well-trained remote coders allows hospitals to attract the level and quality of coders that would not typically be available in any one geographic area. The hospital not only reduces core staff headcount and compensation costs, but also gains the services of certified coders who can decrease errors and turnaround time while capturing additional legitimate charges.

The size of the hospital is not a factor in considering an outsourced remote coding and charging model. Rather, skill and manpower are the two biggest issues. Other facilities across the country that have applied a similar model range in size from fewer than 200 beds to large university hospitals.

Making it work requires a commitment from the facility and an experienced outsourcing partner—one that can provide the staffing and support necessary for quality service, is committed to the hospital’s philosophies, establishes performance guarantees, and holds a reputation for excellence in the industry.

— Cheryl Bowling, RHIT, CCS, CHC, is compliance director for Kforce HealthCare Staffing, a division of Kforce Inc.

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