Net Revenue Matters. A Case for Caution When Considering Staffing Levels

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1 Net Revenue Matters July 2011 Welcome to the July edition of Net Revenue Matters, a publication of Integrated Revenue Management, Inc. We hope that in this issue you ll find several topics of interest. In his article, A Case for Caution When Considering Staffing Levels, Founder & Executive Vice President Jack Duffy discusses concerns regarding hospital staff reductions. Also, we hope that you ll appreciate the information presented in Vascular Closure Device Placement, CMS Issued MLN Matter SE1121 on June 22, and Radiology Reimbursements: Are You Getting Yours? Finally, please note our client corner and upcoming events. We don t want you to miss anything! Inside this issue: A Case for Caution When Considering Staffing Levels 1 Vascular Closure Device Placement 2 CMS Issued MLN Matter SE1121 on June 22 2 Radiology Reimbursements: Are You Getting Yours? 3 Client Corner 5 IRM Is Pleased to Announce... 5 Don t Forget! 6 Upcoming Webinars 7 A Case for Caution When Considering Staffing Levels We read with some concern about the growing list of hospitals that have announced staff reductions in the first half of Several thousand skilled employees have been fired with the reason being either gain in efficiency or anticipation of payments reductions tied to the Affordable Care Act. Several thousand skilled employees have been fired... This rationale may be flawed in a couple of ways. The promised efficiency of the investments in electronic records is not mature. There is a growing concern that some of the critical information required to support medical necessity is being lost in the template record. Hospitals may want to monitor the government audit messages for a few more months before releasing skilled staff members. Of even more concern is attempting to guess what the impact of the ACA will be on staffing needs or budgets. We seem to be losing site of the fact that 86 million baby boomers are getting ready to enter the year period when they will use 75% of their lifetime healthcare spend. There is little to suggest that we will not be stretched to the limits of our facilities and staff to meet their needs. A better course of action may be to consider retraining staff members to perform activities that will lead to higher net income and improved efficiency. A better course of action may be to consider retraining staff members to perform activities that will lead to higher net income and improved efficiency. For almost eleven years, IRM and the supported hospital teams have shown how hospital employees from multiple backgrounds can move from overhead positions to net income producers. A wide range of industry reviewers estimate the gap between earned Integrated Revenue Management 2714 Loker Avenue W., Ste 200, Carlsbad, CA Phone: (760)

2 revenue and banked revenue at $700 to $2,100 million dollars per year. We would encourage hospitals to continue to seek out alternatives to layoffs while at the same time improving net income and building cash reserves. The vast majority of employees who could lose their positions are productive and making a daily contribution to the organization. I have seen first-hand on many occasions the long-term consequences of understaffed departments. The results have often been increased losses and expensive recovery projects, many times with multi-million dollar price tags. So before your organization chooses the reductionof-staff option, consider the alternatives and if there might be a better solution. Vascular Closure Device Placement A vascular closure device is placed at the vascular access site (e.g., femoral artery) to stop the blood flow following procedures requiring percutaneous vascular access (e.g., cardiac catheterization, coronary interventions, interventional radiology). Vascular access sites were solely managed by manual compression prior to the introduction of devices for arteriotomy closure in the early 1990s. There are several vascular closure devices on the market; some include Angiolink, Angio-Seal, Mynx, Perclose, StarClose and Vasoseal. Effective January 1, 2011 vascular closure device placement, described by HCPCS Level II code G0269 is a component of both cardiac catheterization...and lower extremity endovascular revascularization... Effective January 1, 2011 vascular closure device placement, described by HCPCS Level II code G0269 is a component of both cardiac catheterization (CPT code range ) and lower extremity endovascular revascularization (CPT code range ) and not separately reportable. The AMA 2011 CPT Codebook, Medicine Chapter, Cardiac Catheterization section states that closure device placement at the vascular access site is inherent to the catheterization procedure and not separately reportable. The Endovascular Revascularization - Lower Extremity section in the Cardiovascular Section of the CPT codebook states that closure of the arteriotomy by any method is included in the procedure. Revenue integrity/management departments charge audits and coding reviews continue to reveal a charge for placement of a closure device at the vascular access site. Revenue integrity/management departments charge audits and coding reviews continue to reveal a charge for placement of a closure device at the vascular access site. The facility must remove the charge for placement of a vascular closure device for the aforementioned procedures only and adjust the pricing accordingly for the main procedure. In light of the vast changes for cardiac catheterization and interventional radiology services in 2011, facilities should perform a detailed pricing review of all procedures subject to change in the aforementioned areas. The vascular closure device is still separately reported by the facility with HCPCS Level II code C1760. CMS Issued MLN Matter SE1121 on June 22 CMS uses vulnerabilities identified by Recovery Auditors to help reduce the Comprehensive Error Rate Testing (CERT). RAC MS-DRG reviews look at the principal and secondary diagnoses along with procedures which are on a claim. When RAC requests a record, they review the entire record. As many hospitals will code the record without a discharge summary or operative report in an

3 attempt to keep their DNFB low, this may result in RAC determining a different principal diagnosis. The UHDDS defines the principal diagnosis as the condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital. The UHDDS defines the principal diagnosis as the condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital. When determining the principal diagnosis, all documentation by licensed, treating physicians in the medical record must be considered. So, while the H&P and early progress notes may steer the coder in one direction, continued workup and evaluation may determine something entirely different on the discharge summary. If at all possible, the best practice would be to wait for all documentation prior to coding. If this is not feasible, then there must be a process in place to route the chart back to the coder for final review and possible re-submit of the claim with the corrected diagnoses. RAC will not take into account that all documentation was not present at the time of coding. In addition, if there is conflicting or contradictory information in the record, the attending physician should be queried for clarification of the principal or secondary diagnoses. In addition, if there is conflicting or contradictory information in the record, the attending physician should be queried for clarification of the principal or secondary diagnoses. Coding Clinic, First Quarter 2004, page states: Code assignment may be based on other physician (i.e., consultants, residents, anesthesiologist, etc.) documentation as long as there is no conflicting information from the attending physician. Medical record documentation from any physician involved in the care and treatment of the patient, including documentation by consulting physicians, is appropriate for the basis of code assignment. A physician query is not necessary if a physician involved in the care and treatment of the patient, including consulting physicians, has documented a diagnosis and there is no conflicting documentation from another physician. If documentation from different physicians conflicts, seek clarification from the attending physician, as he or she is ultimately responsible for the final diagnosis. This information is consistent with the American Health Information Management Association s (AHIMA) documentation guidelines. So, when coding, ensure that there is clinical evidence in the record to support the coding, query any conflicting documentation, and get a final diagnosis before submitting the claim. Radiology Reimbursements: Are You Getting Yours? A lack of effective communication, when it comes to the dictated radiology report, often leaves coders wondering what has really been performed. Omitted documentation costs the facility valuable reimbursement when the report cannot be coded to the highest level of specificity. Reimbursement is in the report details. Commonly omitted information on a radiology report is the number of views. Omitting this information on the report can result in down coding and lower reimbursement. When an MRI or CT is performed with contrast, or without followed with contrast, and the contrast type, strength, and amount are not documented, it is an open area for a revenue leak. A lack of effective communication, when it comes to the dictated radiology report, often leaves coders wondering what has really been performed. Additionally, some ultrasound studies have specific criteria that must be met in order to code a complete

4 study. For example, the guidelines for an ultrasound of the abdomen must consist of real time scans of the kidneys, abdominal aorta, common iliac artery origins, and inferior vena cava, including any demonstrated retroperitoneal abnormality. If clinical history suggests urinary tract pathology, a complete evaluation of the kidneys and urinary bladder are required for a retroperitoneal ultrasound. We have known this for some time now as coders; however, often the language in the report does not completely meet the CPT guidelines or the code descriptor and results in down coding and loss of reimbursement because anything less of what is listed in the CPT guidelines is a limited study. What is the radiologist forgetting? Technology can work for us; EMR and macros systems can be set to flag the radiologist if something is missing on specific reports prior to electronically signing the final report. If the radiologist isn t aware that there is missing information, and it is resulting in lost revenue, then he/she can not fix it. My suggestion would be to do an audit of the radiology reports and first identify any areas of concern. In addition, as reports are coded, if they are softcoded, the coder can query the physician when it appears that key documentation has been omitted. This in turn can spur a process improvement into action to correct the issue and stop the revenue leak. Providing education to clinical staff and physicians can prove to be the key to successful compliance and reimbursement. What should be included in a complete study? This information is available at the American College of Radiology. To obtain a copy of the ACR practice guideline for communication of diagnostic imaging findings, please visit: guidelines/dx/comm_diag_rad.aspx Coders and HIM departments need to get involved and share knowledge. Providing education to clinical staff and physicians can prove to be the key to successful compliance and reimbursement. Client Corner IRM Is Pleased to Announce... IRM is pleased to announce that database tutorials are now available in the Clients Only area of our Web site. To access the tutorials, please visit: Under Revenue Management Clients, click Clients Only. Enter your address and IRM-provided password and on the Client Only Resources screen, click Tutorials. The tutorials are categorized by sections and to review the database tutorials, choose from the following: CCDR CCDR Overview How to Perform Data Entry on the Audit Findings Tab How to Compact and Repair How to Import How to Open Screens Reports Overview Update Utilities Menu Charge Audit CA Overview Audit Types Data Entry Defense Data Entry Process How to Access Audit Worklist How to Access Inventory Reports How to Compact and Repair How to Import How to Open Screens How to Perform Data Entry on the Audit Findings Tab How to Perform Inventory Worklist How to Price on the PrePost Audit tab How to Run Database Reports

5 How to Update the Utilities Menu How to Access Pricer Reports Managed Care MC Overview Audit Queue Reports Audited No Variance Function Collector Tab Database Reports Compact and Repair Credit Balances How to Open Managed Care Screens Importing IP Worksheet Data Entry OP Worksheet Data Entry Payment Posting Refunds Utilities Menu Writeoffs PI RMetrics RMetrics Trend Tracker Overview Trend Tracker How to Compact and Repair Trend Tracker How to Perform Data Entry on the Education Training Form Trend Tracker How to Run Education Training Reports Trend Tracker How to Enter an Observation in the Observation Log Trend Tracker How to Run an Observation Log Report Trend Tracker How to Open Screens Trend Tracker How to enter PDCA reports Trend Tracker How to update the Utilities Menu If you have any questions, please submit a help desk ticket or contact your Director of Revenue Management at IRM. Don t Forget! All CBR (Code-Based Reimbursement)/CCDR (Compliant Coding and Documentation Review) activity for the month must be entered into the CBR/ CCDR Software applications, including DRG Catalyst, prior to the 10th of the following month. Be sure to follow the steps below so that results from retrospective CBR/CCDR audits translate onto the Executive Summary: Inpatient (DRG Catalyst) The rebill checkbox must be checked. (Please make sure that you send the checked accounts to PFS for rebilling!) Outpatient (CBR Database) The completion date must be entered under the CBR/CCDR Utilities tab, and The rebill checkbox must be checked. (Please make sure that you send the rebill accounts to PFS for rebilling!) Before the database closes each month, IRM recommends that you complete the following checklist: Confirm that all completed retrospective audits for the month have an end date entered into the CBR/CCDR database. Check the rebill box in the CBR/CCDR database or DRG Catalyst for each retrospective claim that has been approved for rebilling. Complete a Summary of Audit Findings form for any projects you closed this month and submit it to the coding Subject Matter Expert (SME). Ensure that data is entered for all accounts audited for the current month.

6 Upcoming Webinars Client RMD/RID Webinars 2011 Jul Aug Potential Topics 20: PI Forum POSTPONED 9: RAC Forum: RAC Updates 18: Managed Care Forum Consumer-Driven Healthcare/Pay for Performance Medicare Managed Care Auditing ICU Accounts How to Handle Adversity Silent PPOs How to Interact with Internal Customers Write-Off Analysis Software Reporting Injections and Infusions Introduction to Inpatient Audits Device Dependent APCs Pain Management Outpatient Orders Spine Surgery Chemotherapy Pathology Brachytherapy Moderate Sedation Radiology Imaging Erythropoiesis Stimulating Agents Discharge Dispositions Emergency Department Vascular Access Devices Neurostimulators GI Endoscopy Tracking and Trending CCI Edits Inpatient Mechanical Ventilation POA and HAC Observation and One-Day Stays Please watch for your invitation approximately three weeks prior to the scheduled event. Thank You Net Revenue Matters is a monthly publication of Integrated Revenue Management, Inc. (IRM), and is offered as an informational service. Due to the nature of this publication, examples cited and advice given must often be general in nature and may not apply to a particular facility or situation. Thus, IRM does not warrant or guarantee the information contained will be applicable or appropriate in all situations. Each facility will have to evaluate its specific opportunities and take such action as to best meet its business needs. To find out more about a given subject or for information tailored to your specific circumstances, contact an IRM professional. If you have questions or would like to submit information for a future newsletter, please contact: Cynthia Hufferd chufferd@irminconline.com