Executive Summary

With the recent switch to ICD-10, coding expertise is now a “must-have” skill for patient access.

“Patient access staff needs to have coding knowledge to anticipate conflicts with services rendered and billing of the claims,” says Christina Bolanos, patient access services manager at Sharp Mesa Vista Hospital and Sharp HealthCare’s outreach laboratory revenue cycle in San Diego, CA.

Many patient access departments are seeing a surge in claims denials because of the switch to ICD-10 coding. “Moving from 13,000 to 68,000 codes has made it very difficult for providers to document their charts to the correct level of specificity required by payers,” explains Karen Hoppe, a senior consultant at Craneware, an Atlanta-based company specializing in revenue cycle improvement.

Physicians do not realize the coding they are using in charts and orders will not meet payers’ medical necessity requirements. Patient access departments are stepping in to provide this much-needed education.

“The focus really needs to be on improved clinical documentation,” says Hoppe. “Patient access teams need to establish a good feedback loop with the physicians’ offices.”

Weeks to Resolve

Sharp HealthCare’s outreach laboratory revenue cycle department had an uptick in denials for laboratory services. This was due to incorrect coding and overuse of generic codes.

“There was a lot of time wasted on the patient access side to get the correct information. This delayed the release of the claim to the payer,” says Bolanos.

Many missing or incorrect diagnosis codes were related to the switch to ICD-10 coding. For instance, under ICD-9 coding, “V70.0, routine medical exam,” covered multiple diagnostic tests. This is no longer the case. “Most practices believed V70.0 was updated to Z00.0 with ICD-10, and would still cover a multitude of tests,” says Bolanos. A fifth digit or a more specific code is needed.

Another common error is the use of “E78.0, pure hypercholesterolemia” on lab orders. “This code requires a fifth digit for a greater level of detail,” says Bolanos.

Each time the less-specific, incorrect code was used, patient access had to call the physician’s office to ask for a new order with the fifth digit added. Patient access had no way to know which digit it should be without getting additional clinical information. The 0 digit indicates pure hypercholesterolemia unspecified, for instance, whereas the 1 digit indicates a family history of pure hypercholesterolemia.

“It was a bit of a long process,” says Bolanos. “It sometimes took weeks to resolve.” To fix the incorrect code, phone calls, faxes, and in-person visits were needed. Despite all these efforts, denials and delayed payments were common.

First, patient access contacted the receptionist at the physician’s office, and explained they were calling for an incomplete diagnosis code. The call was transferred to the medical assistant line, and a message was left. Several days typically passed without a return call.

After getting no response, patient access then faxed the lab requisition with a cover sheet stating that there was an incomplete code that needed to be fixed before the claim was submitted. Even then, the office didn’t always respond.

This meant that patient access managers had to take the time to directly contact the office managers. In some cases, patient access even involved sales reps, by asking them to pick up the lab requisitions and go to the office to get the corrected coding.

The department identified 10 physician offices that were submitting incorrect codes consistently. Patient access leaders visited them in person to explain how the coding mistakes were affecting the billing process. “We requested the office manager and the main medical assistant to be present. This personal approach worked well for both sides,” says Bolanos.

Bolanos brought the actual lab orders with her to show how each one had missing information or the wrong coding. The office staff was unaware of the specificity that was required with ICD-10. “We also explained how they, too, would be impacted, when it came to their own office visit billing,” says Bolanos.

Together, patient access and the physicians’ offices established a more efficient process. Instead of many phone calls that were usually ignored, a request is faxed just once. The office staff promised to act promptly when a fax came through. “The offices assigned staff to reply twice a day to the requests,” says Bolanos.

Both patient access and providers’ offices save time with the new process. Patient access no longer makes time-consuming phone calls, and physicians’ offices get fewer interruptions. “We are working together and resolving items timely,” says Bolanos.

Make It a Requirement

To stem the tide of denials related to incorrect coding, patient access departments are revamping job requirements to include coding skills. “To reduce denials, it should be required that patient access management be credentialed coders,” says Dorothy D. Steed, an Atlanta-based revenue cycle consultant and educator.

Coding skills are part of a bigger movement toward highly trained patient access employees, says Steed: “Management must accept that general clerical or customer service skills are no longer adequate.”

Steed recently worked with a hospital to revise job descriptions for the precertification department. All new hires must have a credential from the American Association of Professional Coders — either the Certified Coding Specialist-Physician (CCS-P) or the Certified Professional Coder (CPC). Alternatively, employees can have a minimum of five years’ experience in general coding knowledge as demonstrated on a pre-hire test.

Existing staff were given the option of attending 80 hours of formal coding training or transferring to another area. There was some initial pushback from employees, particularly those with long-time status.

“This is why it was vital to engage HR to ensure that there would be no unexpected repercussions,” says Steed. HR developed an employee agreement on the position restructure and coding knowledge requirements.

Two employees decided to leave the department and retired earlier than they had planned. Another employee already had attempted the coding test unsuccessfully, but passed on the second attempt. All the other employees attended the training and obtained the credential.

“Class was divided into half days, with half of the staff attending mornings and the other half attending afternoons to provide departmental coverage,” says Steed, who taught the course. The department covered the cost of training, books, and the cost of the exam.

“Those who passed were given a pay increase, worked out by management and HR,” says Steed.

Previously, coding that did not meet medical necessity requirements went unnoticed until the claim got denied. Armed with coding know-how, patient access spots the mistakes early. Most are corrected by providers before the claim goes out.

“Obtaining a stronger initial reason for service reduces medical necessity denials and the need to develop appeals,” says Steed.

SOURCES

• Christina Bolanos, Patient Access Services Manager, Sharp HealthCare Outreach Laboratory Revenue Cycle/Sharp Mesa Vista Hospital, San Diego. Phone: (858) 836-8601. Email: Christina.Bolanos@sharp.com.
• Karen Hoppe, Senior Consultant, Craneware, Atlanta, GA. Phone: (781) 789-4272. Email: K.Hoppe@craneware.com.
• Dorothy D. Steed, Atlanta, GA. Phone: (404) 234-8676. Email: dot@dorothysteed.com.