As part of my CAC project, I learned how to audit previously coded cases for accuracy. Scenario given to me had lot of coding error such as selecting undefined PDX, non-sequencing, very less details in secondary diagnosis etc. I was able to abstract required information from the system and highlight the deficiencies/coding errors. I learned that auditing is a crucial & important process to maintain the accuracy of coding and improve the reimbursement for healthcare providers.
As part Healthcare revenue manage class, I learned that Healthcare revenue cycle is the financial process that healthcare facilities use to manage the administrative and clinical functions associated with claims processing, payment, and revenue generation. The process encompasses the identification, management, and collection of patient service revenue.This process begins with patient's first appointment to seek medical services and ends when all claims and patient payments have been collected.
Payments under Medicare program for inpatient hospital services are based on IPPS and services that are unrelated to POA are billed separately and hospitals can see adjustments based on HACs. There are list HACs for which CMS does not reimburse that means it is a lost revenue for Hospitals.
In my coding class, most important thing I focused on assigning ICD diagnosis codes which supports medical necessities and these ICD-10-CM diagnosis codes are in the center of the revenue process. Any claim submission with diagnosis codes reported with the service gives the payer "why" a service was performed. The diagnosis reported helps support the medical necessity of the procedure. Any error in ICD codes directly impacts revenue as well as data analytics, mandatory compliance reporting etc.
To reduce the revenue leakage, hospitals charge master is center of billing process. Charge master maintains the costs of each procedure, service, supply, prescription drug, and diagnostic test provided at the hospital, as well as any fees associated with services, such as equipment fees and room charges. Maintenance of charge master is a continuous process and managed by a dedicated team of HIM professionals. They need to enage with all the departments and ensures all services are accurately charged, the hospital is compliant with government regulations for pricing, and the organization receives accurate reimbursement.
Improved reimbursement is the first goal of any organization, and by Managing discharged not final billed (DNFB) cases, where bills remain incomplete due to coding or documentation gaps, is one important way providers can improve financial performance or/and by maintaining the case-mix index (CMI) so that big ticketed procedures are key to increase the reimbursement or/and reducing the coding-turn-around-time. All these measures are dependent on the good documentation practice with well trained staff.
I also learned that, main reasons of denial of claims is due to lack of specificity in claim. Coders can engage with CDI to improve the documentation and share the coding specificity required to capture the severity of patients’ conditions.
As part of Revenue cycle audit case study, I found the claim rejection reasons and drafted the letter which includes patient diagnosis documents including procedures rendered, including Coding Guidelines and Coding Clinics.
Artifacts:
CAC Project, Revenue cycle audit case studies, CDM project, Revenue cycle management process map