November 2014Service Documentationrevenue cycle acaDemy Journal

Healthcare Business Insights

As providers continue to experience increas-ing challenges regarding the attainment of proper reimbursement, many leaders are reassessing charge capture workflows in order to reduce revenue leakage, deni-als, and preventable delays in payment. To this end, many organizations are creating specialized charge-related roles and staff-ing them with team members knowledge-able in coding or clinical care to enhance processes. To support these staff members, providers are also looking to leverage capa-bilities within their electronic health record systems to reduce the amount of time spent auditing charges and improve compliance with payer regulations.

To learn more about how organiza-tions are optimizing charge capture pro-cesses, The Academy recently spoke with Chloe Phillips, Director of HIM and Clinical Revenue at Baptist Health System (BHS)—a four-hospital provider based in Alabama. By effectively allocating roles to charge integrity and designing effective work queues, this organization has been

Considerations for Improving Charge Capture Processes able to improve its rate of charge capture

as well as staff performance.

Enhancing Outpatient Charge Capture ProcessSeveral departments—including coding,

HIM, clinical revenue, and chargemaster—

are centralized at the service level at BHS,

meaning that workflow and reporting struc-

ture is consolidated across the system.

Given the interrelatedness of clinical and

financial functions, these departments all

report up to Phillips. “While it may seem

unique to have these departments under

the same individual, it has been a successful

transition over the years,” Phillips explains.

“Our team works great together, and as a

result, we’ve seen huge success at BHS both

prior to and post-Epic implementation.”

The coding team is responsible for coding

impatient and outpatient services across

the enterprise, which includes its four hos-

pital campuses. One particular area of focus

for this team includes applying infusion,

injection, and observation hour charges

that are payer compliant and supported by

documentation. “We assumed responsibil-

ity of these functions years ago, so we were

in a great position to work with Epic when

As reimbursement challenges mount, many providers are looking to enhance clinical documentation improvement (CDI) pro-grams as a way to ensure documentation fully supports the quality of care provided and promotes accurate coding, billing, and clinical quality scores. With ongoing prepa-rations being made for ICD-10, the level of

CDI Best Practices: Examining the Case for Daily Rounds and Stratifying Specialists by Service Line

specificity required for documentation will

necessitate CDI staffing structures that

facilitate a strong alliance between clinical

documentation specialists (CDSs) and phy-

sicians to secure their compliance.

Recognizing this as an area for improve-

ment, two CDI trends providers may wish to

consider include having CDSs go on daily rounds with physicians and dedicating them to specific service lines. Understanding the benefits and challenges of these strate-gies can help leaders determine a best-fit strategy that will help organizations meet the increasing demands for specificity and secure appropriate reimbursement.

Involving CDSs on Daily RoundsBecause physicians’ primary concern revolves around patient care, they may be apprehensive about revenue-centric ini-tiatives like CDI programs. Physicians will ultimately create the documentation, but CDSs can help influence the inclusion of necessary components and phrasing that results in accurate coding. Therefore, build-ing strong working relationships between

SEE CDI ON PAGE 3

SEE CHARGES ON PAGE 2

Given the complexity of charging for observa-tion services, it may be beneficial to dedicate staff members—often coders—to this task to improve compliance.

Responsibility for Capturing Outpatient Observation Charges

Source: Academy Survey Results

Nursing Staff 26.5%

HIM/Coding Staff 36%

Charge Capture

Staff 26.5%

Other 11%

Physician Engagement

First-Hand Experience

Education and Feedback

Rounding Medical Staff can develop personal relationships with CDSs and grow to trust their input

CDSs can hear first-hand the medical team discuss patients’ care—increasing overall understanding of the case

CDSs can give medical staff feedback in real-time and reduce the need for later follow-up or query

Service Line Allocation

If viewed as an interruption, rounding may deter building relationships; centralized service line allocation may help in this regard

Staff may be able to obtain the same experience by simply being housed in a clinical workspace frequented by physicians

Using a clinical workspace allows staff to be easily located at any point in the day by medical staff for questions

Common Benefits of Physician Rounding and Service Line Allocation

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we built our charge capture workflow and

work queues,” Phillips notes. Prior to its go-

live, BHS tested charge capture workflows

to ensure the system met organizational

needs. Such a review also gave the organi-

zation the opportunity to identify areas for

focused coder training—helping facilitate a

smooth transition.

For infusion and injection services, cod-

ers use an application in the EHR to pull

information captured by the Epic Mobile

Augmented Reality (MAR) browser

from emergency room and observation

accounts, which includes the specific

medication, route, dosage, and time it was

given. “Using this application for injections

and infusions charging as it is structured

ensures all the necessary documentation

and charging links are available within

one application,” Phillips explains. “This

function has helped us to improve coding

workflow, allowing staff to focus more on

diagnosis and procedure coding.”

The coding team then enters appropriate

charges into Epic’s charge capture appli-

cation. After observation hours are cal-

culated, coders select the correct charge,

quantity, and date. The time the patient

was in observation is noted within the

“Events Summary” section and excluded

from the total observation hours charged.

By using these applications, BHS was ulti-

mately able to improve productivity and

turnaround time on charge capture based

on payer specific guidelines—allowing the

organization to maintain its rate of A/R

held in coding at 1.6 days.

Involving Clinical StaffTo further promote charge integrity, orga-

nizations may find it beneficial to col-

laborate with clinicians to ensure that

root causes of charge capture issues are promptly addressed. With this mind, BHS elected to involve the chargemaster man-ager, nurse auditors, and file specialists within the clinical revenue department in reviewing claim edits for user errors and master file errors built into Epic, which are driven to these staff members on a daily basis through work queues. In addi-tion, clinicians are in charge of reviewing and resolving edits prior to billing based on rules established to specifically pick up on correct coding initiatives, medically unlikely edits, and other procedure-related errors regarding quantity or modifiers.

Phillips expresses the importance of hav-ing department leaders and staff within the clinical revenue department work together to recognize charge-related errors. “There must be department managers and front-line staff supporting the daily audit of rev-enue and usage reports,” Phillips notes. “Working together is the key.” By including clinical staff, like nurse auditors and the chargemaster manager in the charge cap-ture process, BHS has been able to more effectively compare clinical and financial

records to ensure that documentation pro-vided supports the patient charges listed.

Engaging CDM Staff Before transitioning to Epic, BHS had one charge description master (CDM) coor-dinator in each facility that would handle daily charge capture processes. However, due to streamlined charge capture capa-bilities, BHS has been able to consolidate these responsibilities into one CDM man-ager position for the entire system.

The CDM manager is responsible for hold-ing department managers and clinical leadership accountable for daily charge reconciliation processes and ensuring that services charged correspond with ser-vices documented for each encounter. “We have work queues that capture charges for ‘missing revenue codes’ and ‘not allowed cost centers,’” Phillip states. “The area that had the most volume after go-live was the ‘not allowed cost center,’ which was due to users logging into the wrong departments or picking charges from another depart-ment using the search option.” As one solution to address this issue, department managers discussed proper log-in pro-tocols with staff members via email and onsite meetings to mitigate the need for future rework.

Leaders looking to enhance charge capture efficiency and accuracy may benefit from the strategies discussed above. By part-nering staff from both clinical and finan-cial departments and developing effective charge capture work queues, providers can minimize the need for rework downstream, promote payer compliance, and mitigate denials—ultimately helping to improve their financial health.

FROm CHARGES ON PAGE 1 Duties of Nurse Auditors in BHS’ Clinical Revenue Department

Front-End Claim Edits Back-End Claim Edits Review/Audit Process

• Work all claim edits for med-ical necessity and CCI

• Identify missing or com-bined charges, overcharges, or those applied to the wrong account and HCPCS codes

• Combine outpatient accounts to related inpatient accounts within three days

• Correct quantity errors for lab and pharmacy

• Identify combined charges

• Address any issues not caught during front-end claim edits

• Work back-end claims as needed

• Review fiscal audits and respond with appeal letters as needed

• Audit to ensure documenta-tion supports charge

• Additional reviews for dis-crepancies for ED, radiol-ogy, physical therapy, and other services

BHS Organizational Chart Staff Involved in Charge Capture Process

By allocating individuals with specialized knowledge throughout various departments to charge capture tasks, BHS has been able to better promote charge accuracy.

Vice President of Revenue management

Director of HIM and Clinical Revenue (Phillips)

Clinical Revenue Supervisor:• Charge poster• Nurse auditor• IT file spec. HIM and Vendor Staff

HIM Site ManagerCoding Manager:• IP/OP coders

and leads• Training spec. • Coding auditor

CDM Manager

IVR Coder

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physicians and CDSs is essential to a pro-

gram’s success. To this end, many providers

have found it beneficial to include CDSs on

daily rounds with physicians.

For instance, one health system based in

Arizona has remote CDSs who take turns

working onsite Monday through Friday

(with coverage from 6:00 am to 6:00 pm) at

an assigned facility. When onsite, special-

ists conduct rounds with physicians to talk

through questions as they arise and seek

out in-person responses for pending doc-

umentation queries. On the other hand, a

526-bed organization in Vermont assigns

CDI staff to a core group of physicians

to work with over a long-term basis and

accompany them during patient rounds

when clinical evaluations are taking place.

This enables staff the opportunity to make

inquiries in real time, proactively pinpoint-

ing areas that may need further docu-

mentation specificity. Furthermore, this

approach allows for a bit of cross-train-

ing; not only do CDSs educate physicians

on what constitutes compliant documen-

tation, but physicians are afforded the

opportunity to educate CDSs on higher-

level anatomy and physiology—which will

be important for mastering ICD-10.

Completing rounds with physicians, how-

ever, can be a time consuming process.

An 860-bed academic organization in

Washington realized that physicians on

rounds were often more focused on creat-

ing their plans for the day and assessing

patients rather than thinking about what

exactly to document. In this respect, hav-

ing staff on rounds could potentially deter

relationship building, as physicians may view the presence of a CDS as a detrac-tion from their focus on patient care. “They spent two to four hours in rounds, and some physicians do very prolonged rounds depending on their teaching style, so in the end, we didn’t think it was the most effi-cient use of [CDS’] time,” the CDI manager at this organization notes.

As such, this organization opted to house four CDSs in a general workspace on cam-pus, while the other four CDSs are sta-tioned among the various clinical staff areas, which still affords them access to medical staff and the opportunity to dis-cuss cases with them personally. This leader admits, however, that initially con-ducting rounds did assist CDSs in building credibility with physicians in their respec-tive area, ensuring that physicians now know where to find them regarding ques-tions that arise.

Organizing Staff by Service LineIn addition to promoting physician engage-ment, many organizations are looking to organize CDI staff workloads in a mat-ter that promotes specialization and, as a result, drives documentation accuracy. To this end, some revenue cycle leaders have allocated CDSs by specific service lines, which may also help to build more personal relationships between specialists and physicians. A 969-bed health system in Pennsylvania that assigns CDI staff to spe-cific service lines—including cardiology and oncology services areas—found that specification enabled it to increase capture rates of complications and co-morbidities and improved case mix index across mul-tiple areas.

In addition, specializing by service line can ease the leaning curve for the ICD-10 tran-sition, as staff members would not have to become experts in all 140,000 codes, but rather a select subset. Working long-term on a service line can also increase staff’s knowledge of their specific clinical area and give them a better understand-ing of how their assigned team documents patient encounters.

Specialization can lead to difficulties, though, when it comes to covering CDS’ paid-time off. Because staff is highly spe-cialized, it may be difficult to maintain optimal coverage and productivity during absences. The workload for various service lines might be inconsistent, as well. “[A]

potential downside to doing service cov-erage is that one person may get a light couple of weeks or months because there are major surgical conferences and all the general surgeons are going to be out of town, so their scheduling goes down, ver-sus someone who works with a service that [is focused on] whatever comes through the ED—that person may get very high vol-umes,” the CDI manager at the Washington organization states.

Identifying a Best-Fit ModelBy understanding the benefits and poten-tial challenges of these CDI structures, leaders can implement a best-fit strat-egy for their provider. For instance, one 450-bed organization in North Carolina employs nine CDSs, most of whom have nursing backgrounds and are allocated by service line—including general medicine, surgical, and cardiac services; for instance, three staff members work cases for cardiac surgery and cardiac medicine. Specialists work on their respective floors alongside physicians, while additional specialists were moved from being located within case management to being physically located within the HIM department to also improve communication with coders.

By having CDSs complete rounds with physicians and/or allocating staff by ser-vice line—or a customized combination of those strategies—organizations can pro-mote accurate documentation in the face of ICD-10. Regardless of the exact approach taken, reviewing the tactics outlined in this article may assist leaders in optimizing their CDI programs to ultimately promote documentation integrity and preserve their financial health.

FROm CDI ON PAGE 1

• Ensure that documentation is accurate, complete, and compliant

• Conduct chart reviews to assess pres-ent documentation, and when nec-essary, query physicians to resolve documentation gaps

• Identify opportunities for and develop education to help drive process change

• Expand physicians’ knowledge in what constitutes accurate, complete documentation

• Secure physician involvement in initiatives

• Help track and trend data related to financial outcomes

Common Dates of Clinical Documentation Specialists

Rounding and service line specification, can help promote physician response—the Pennsylvania organization improved its query response rate by 10% in one year due in part to service line assignments.

Query Response Rates at Organizations Featured in Article

Arizona Organization (Rounding)

94%

77%

Pennsylvania Organization (Service Line)

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Service DocumentationResources & Tools • Tips • Trends – for HIM Leadership published monthly by Healthcare Business Insights

rca-research@hbinsights.com • 888.700.5223

Health information management lead-ers have utilized The Academy’s ad hoc research service this past quarter to gain insight into a variety of industry topics—from increasingly prevalent roles like charge entry specialists and coding educa-tors to educational materials on service-specific coding scenarios and emerging best practices in the realm of clinical documentation improvement (CDI). The Academy highlights five resources below that were developed in response to recent Analyst Advisory requests.

Charge Entry Specialist Performance AppraisalAccording to Academy research, a growing number of hospitals and health systems are relinquishing charge entry duties from either clinical staff or coders in favor of a dedicated charge entry or charge capture specialist. Among those allocating charge responsi-bilities in this way, many have experienced tremendous increases in charge accu-racy, and therefore, reimbursement. Given the potential impact of this position, The Academy provides a template with which to rate charge entry specialists’ abilities in areas like aligning applied charges against charge sheets or encounter forms and appropriately assigning modifiers.

Guidance on Modifiers GA, GX, GY, and GZGiven the expansive set of codes charge cap-ture and coding staff need to know, learn, and apply, items that are simply informa-tional versus necessary to secure reimburse-ment may be easily forgotten or misused—especially modifiers. This sample reference

Ad Hoc Research Highlights: Assessing Charge Entry Staff, Educating Coders, and Evaluating the CDI Program

sheet on “G” modifiers may assist leaders

in educating staff, as it provides explana-

tions of how scenarios related to medical

necessity and Advance Beneficiary Notice

of Non-coverage (ABNs) affect accurate

modifier application, as well as an easy-to-

understand decision tree.

Coding Tips for Biopsy ServicesSimilarly, this tips sheet

may help coders better

understand recent CPT

code changes for breast

localization, biopsy, and

imaging services. While

some codes in this fam-

ily were recently deleted,

others were added to bundle these services

into a single CPT code. Included are several

key terms and updates, guidance on how to

code particularly complex biopsy services

or scenarios, and links to additional indus-

try resources on this topic. With nearly one

million breast biopsies provided nation-

wide each year, according to the Centers for

Medicare and Medicaid Services, this is an

area where coding could have significant

implications on reimbursement.

Coder Educator Job DescriptionWith so many changes

occurring among cod-

ing regulations—from

annual updates to the

ICD-10 conversion set to

go live next October—

some organizations

have resorted to allo-

cating a full-time position to coder educa-

tion. This role provides a centralized avenue

of information, as they are typically required

to remain up to date on and disseminate

coding changes while also onboarding new

hires. In addition, coder educators may be

responsible for developing and providing

education related to ICD-10, as well as regu-

larly auditing coding and documentation to

remain attuned to staff performance and ongoing training needs.

Checklist of CDI Best PracticesEven when coders are highly trained, sea-soned, and knowledge-able, their ability to code accurate diagno-ses and level of ser-vice rests squarely on the quality of clinical documentation. While most organiza-tions now have a clinical documentation improvement (CDI) program in place to support documentation integrity, the rate of variability regarding program staffing, structure, and operation—even from one organization to the next—reveals not just its relative infancy within the industry, but also how successful programs can differ in their approach. While, in acknowledg-ing the integral role CDI can play in both financial and clinical performance, this checklist examines various strategies lead-ers have found to contribute to quantifiable improvement and physician engagement.

Through the Analyst Advisory research service, The Academy continues to assist members in effectively allocating, edu-cating, and assessing mid-cycle staff. As leaders continue to develop new roles and strengthen the knowledge of existing staff in response to impending changes, the above resources—along with other Academy materials—can be leveraged to support a well-allocated workforce, create effective policies and procedures, and pro-mote compliance with internal and exter-nal standards.

If you would like to make a research request or obtain copies of any resources detailed in this article, please contact The Academy at 888.700.5223 or log on to the member portal to access the online archive of Analyst Advisory Research Studies.