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October 18, 2004

Mobile Charge Capture Technology: Coder Friend or Foe?
By Cynthia Trapp, CHFP, CMPE, CPC, CCS-P
For The Record
Vol. 16 No. 21 Page 14

Professional coding is essentially the backbone of healthcare’s payment schema—a highly organized process for determining medical services rendered and the dollar value due each. To outsiders, and even to some physicians, the multitude of alpha-numeric “codes” that professional coders deal with daily is frequently mystifying. Further, the notion that every service provided requires documentation via proper use of the most appropriate service codes (from 8,100-plus procedure codes used in combination with one or several of nearly 15,000 diagnosis codes) is something that most patients are not aware of. And to further complicate matters, these codes must be used in adherence to a multitude of governmental and payor contract regulations.

As the director of professional coding at Lahey Clinic in Burlington, Mass., it is my job to make sure that for the 450 physicians who practice here and the roughly 3,000 patients those physicians see on a daily basis, coding is done correctly and efficiently. When bills are generated quickly and accurately, it’s a win-win situation—our physicians are paid in a timely manner, and ideally our patients never have to worry about whether or not the right coding was applied to their recent office visit. They have enough to worry about in managing their own well-being.

Managing this process for an institution the size of Lahey is no small challenge. My team consists of nearly 50 professional coders, the majority of whom are certified professional coders. In fact, many have multiple certifications. And because most of our coders actually work right in the clinic areas, elbow to elbow with the physicians, they are very much tuned in to the daily flow of patients and the types of procedures being performed.

Given the size and proficiency of our team and the close relationships between the coding and clinical staffs, you can imagine that the terms mobile charge capture and point-of-care coding were slightly disconcerting when first mentioned as an organizational initiative in 2001. Not only were these terms new to some of the team members, but the notion that paper encounter forms could be replaced by handheld devices was one that few healthcare organizations had embraced at that time.

But as Lahey has long been a leader in clinical innovations, we also sought to be an early adopter of health information technology—specifically, technology capable of improving our operational efficiencies. The belief was that if patient encounters could be electronically documented (as opposed to paper) at the point of care using real-time coding assistance in the form of rules and alerts running on the handheld devices, our claims could be generated cleaner and faster. While this was exciting news for the institution, what did it mean for the professional coders who had always played such an integral role in our coding and charge capture process?

The Infamous Moving Cheese
Given the momentum that point-of-care solutions for coding and compliance are now experiencing as a result of their documented ability to improve a healthcare organization’s revenue cycle, more and more professional coders are probably asking themselves those same questions. Indeed, the implementation of new technology that seemingly replaces certain job tasks can be perceived as threatening at first. But at Lahey, three years after first hearing about mobile charge capture, our coding staff now wonders how they ever got by without it.

Before Lahey implemented mobile charge capture, our coding process was typical. Physicians recorded services rendered to patients, as well as corresponding diagnoses, on paper encounter forms, listing the most common codes specific to a physician’s specialty or group. At the end of each day, completed encounter forms were batched and forwarded to the coders for review and/or editing. If the encounter forms were complete, they would then be sent along for billing; if the forms were incomplete or illegible, manual intervention was required. This intervention usually consisted of the coder having to physically locate the physician to gather the missing information.

Not only did our old process involve upward of six individuals “touching” each encounter form, but we also had to apply stringent controls for the tracking, transportation, and storage of the forms. (And regardless of the various controls we employed, there was always the risk of losing forms while in transit.) In addition, this process also created multiple lags—it was often several days after a patient’s visit that his or her charge actually made it into the billing system, which served to delay our receipt of payment from the patient’s insurance company.

By moving to mobile charge capture, we believed that our cumbersome coding and charge entry process would be dramatically streamlined. Because physicians would be utilizing handheld devices to capture and wirelessly transmit patient charges from the examination area to his or her coding and billing support team, we would no longer have to deal with the multitude of paper encounter forms. Moreover, charges would be entered into the billing system almost immediately, reducing—if not eliminating—both the entry and payment lags.

All Aboard
The coding staff embraced this new process, even though they knew it meant their day-to-day job responsibilities would change significantly. The first major change was the elimination of the paper encounter forms—all charges would have to be reviewed on-screen via a companion desktop application. Further, with compliance rules and alerts, such as Local Coverage Determinations and Correct Coding Initiative rules, running on each physician’s handheld, the team was initially unsure of how this would impact what they’d actually be reviewing. As to be expected, there was slight concern as to whether or not these rules were intelligent enough to replace the skill sets of the coders, gathered and refined over years of training and experience.

The answer: a resounding “no.”

Even though the physicians were greatly helped by the rules in terms of understanding coding violations, the act of actually coding a patient encounter—selecting and linking codes, understanding the differences between NEC (not elsewhere classified) and NOS (not otherwise specified), applying the correct modifier—was something some physicians had never done before. To support the physicians during their acclimation to both the handheld devices and the coding application, we actually trained the coders on their own devices so they could work with the physicians one on one. The coders essentially became the physicians’ coding mentors.

And while supporting the physicians—as well as the new software—was an added job function, it was met with enthusiasm. Not only did it further open fairly well-established lines of communication, but the coders also enjoyed their increased face time with the physicians, providing feedback and information they previously had difficulty getting the physicians to attend to.

Other ways mobile charge capture has enhanced the role of the professional coder at Lahey include the following:

• The ability to understand and report on physician coding trends in a timely manner. Physicians find this information tremendously valuable given the impact it has on their reimbursement levels. These trends had previously been quite complicated to identify and communicate given the lags involved in the paper-based process.

• Improved efficiency. Not only do coders no longer have to spend time tracking down physicians with questions about handwritten codes and notes, but they also no longer have to wait for charges to be batched for their review to commence.

• Professional growth. Now that we were operating with a highly streamlined workflow, the coders were able to spend time doing things they simply hadn’t enough time to do previously, including documentation review and partaking in continuing education opportunities and research projects.
Moreover, the coders knew they were a critical part of a successful initiative. As a result of their willingness to take on additional tasks and learn new technology, the physicians felt supported during this new endeavor. This support gave the physicians a comfort level with both the application and the process of coding and enabled them to stick with it. Our coders were most pleasantly surprised by the success of the program. Here is what a few of them have to say about its specific benefits:

• “The efficiency of mobile charge capture has enabled me to capture charges that were sometimes inadvertently indicated as post-ops, as well as to rectify a visit within the global period before processing.”

• “I think this product has given us the opportunity to interact more often with our physicians with regard to overall coding issues. The reality [is] that they now have the coding tools to carry around with them in the form of handheld devices, resulting in more coding inquiries and more opportunities for education and awareness.”

• “The ability to actually see each code that each physician has reported via the Web alerts us to any problems that may need to be addressed as opposed to looking at each and every paper encounter.”

• “It saves time. There is no paperwork, so there is no running around the hospital delivering coded encounters to data entry staff. There is also no waiting for charges to be batched and no problems with legibility.”
While the implementation was a success in terms of change management and role adaptation, there were also tangible benefits that had significant positive impacts across the organization. Results from a return-on-investment study demonstrated the following:

• “Lost charges” had been eliminated.

• The average time from patient encounter to charge entry was reduced to less than one day.

• The average time from claim submission to receipt of payment was reduced by more than 10%, or 4.2 days.

Coming Soon to a Practice Near You?
With so much discussion at the government level about the value of information technology in healthcare, it’s probably only a matter of time before your organization moves to implement one of the myriad financial or clinical systems poised to improve efficiency. Should mobile charge capture become an initiative at your practice, here are some insights to help manage the changes—and in some cases challenges—you will surely face:

• Physicians will always require assistance with coding. Supporting your physicians will help them truly understand the body and complexity of knowledge you have obtained through your professional coding education and experience.

• Paper is viewed as a healthcare safety net, but in actuality, accuracy depends on electronic technology. With proper testing and a successful implementation, claims are significantly more accurate as they flow from one system to another (rather than risking human error as the paper passes through several different sets of hands). There is nothing that can be done using a piece of paper or coding manual that can’t also be done using computers. It may take a little more time at first, but the learning curve will diminish quickly.

• Successful implementations get noticed. Being part of a project that can improve an organization’s revenue performance and daily operations is likely to increase your own visibility.

• Think long term. Learning any new skill only enhances your personal marketability.

Given the fact that Lahey is considered an early adopter of mobile charge capture, it’s provided me the opportunity to speak with organizations who are interested in what we’ve been able to do and how they might replicate a similar process. I always make it clear that we did not view mobile charge capture as a tool to replace valued staff and their skills with automation. Instead, our goal was to achieve operational efficiencies and revenue improvement so we could continue to deliver cutting-edge, quality medical treatment, as well as expand our technology offerings to attract and maintain the best physicians.

Change is never easy, but as anyone who works in healthcare knows, it’s inevitable. While the types of codes used to document a service or diagnosis may evolve over the next few years, reimbursement levels will always be tied to an organization’s ability to submit clean and timely claims. Adopting a tool like mobile charge capture as a means to that end can create a lot of anxiety, but as the coders at Lahey found, it doesn’t take long before the benefits spur tangible role enhancements.

— Cynthia Trapp, CHFP, CMPE, CPC, CCS-P, director of professional coding at the Lahey Clinic in Burlington, Mass., has served as a project lead for Lahey’s implementation of MedAptus’ mobile charge capture application.

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