In years past, patient access had little or no knowledge of coding. This has changed.
“As payment models and coding requirements change, more training is necessary,” says Jannifer Owens, revenue cycle content manager at St. Paul, MN-based 3M. True coding expertise comes from structured training in anatomy and physiology, successful completion of a coding exam, and years of experience, Owens says.
Patient access staff need far more limited knowledge of coding to perform their jobs. However, it is vital that they learn some basic skills. “Patient access is the first line of defense from a payment perspective,” Owens notes.
Above all, patient access needs a good understanding of medical necessity and why claims might be denied. “Staff should also have knowledge in other areas, such what’s required on an order and what requires an authorization for payment,” Owens says. They also need to understand Advance Beneficiary Notices and modifier requirements. “They wouldn’t need to be an expert,” Owens says. “But they do need to have the skills to ensure compliance.”
From a medical necessity perspective, if incorrect diagnosis codes are used, a claim is going to be denied. “This means that it generally will come back to billing, then coding, then potentially the provider,” Owens explains. At the very least, this delays payment for weeks or months. It is always possible the reworked claim ultimately will be paid. “But the cost of working the denial may outweigh the payment from the initial test, study, or procedure,” Owens cautions.
Different payers use different requirements for medical necessity. “Staff need to have access to medical necessity software for a variety of payers, or at least know how to search for the information,” Owens suggests. Sometimes, a specific test is ordered and conducted, but no valid diagnosis is present to support the test. This often happens with Medicare denials.
“Medicare has coverage determinations that instruct staff on what codes will pay for which procedures,” Owens explains.
To train patient access staff in coding skills, clearly identified expectations are essential. “You are not looking to make the patient access staff coders,” Owens explains. “You are training them to recognize, understand, and act on areas of impact.”