Screening can ease medical necessity burden

Software flags wrong code during phone call

When it comes to complying with Medicare’s medical necessity rules, the issue is "where you police the system and who polices it," says Balil Ezzeddine, PhD, imaging research and development director at Kettering (OH) Medical Center.

Physician orders should be screened for medical necessity at the point of scheduling, contends Ezzeddine, whose hospital is a beta test site for a new medical necessity module by Jacksonville, FL-based Tempus Software. The medical necessity software, Comply, works with Encompass, the vendor’s enterprise patient scheduling product.

Hospital staff who attempt medical necessity screening at the point of service have missed an opportunity to handle the situation through a phone conversation between schedulers and the physician’s office, he says. "When a physician who is not trained to give the right ICD-9-CM code orders an exam, his ignorance trickles all the way back to the billing department. How do you start policing so in the end you educate all the physicians to learn to use coding principles and guidelines?

"There’s no way we can immediately educate all physicians, so at the same time we have to start making checkpoints and try to feed the information back to the physicians," he adds. "The best checkpoint is at scheduling. That’s when you want to put in a filter to say [to the physician], If you’re giving me the wrong indication for this diagnosis, please fix it.’ You don’t have to call the physician back [or] track him down."

Screening during scheduling also eliminates the awkwardness of having the patient sign a waiver — on the spot — accepting responsibility for the cost of the procedure if it fails medical necessity, he notes. Instead of learning there’s a problem as they wait to have a procedure, patients can be notified well in advance.

With Encompass Comply, the scheduler selects the patient, the procedure, and the ordering physician on the computer, explains Matt Lang, director of marketing for Tempus. Encompass prompts users for the ICD-9-CM diagnosis codes, allowing them to select from a pre-defined list of valid codes. The system checks the combination of diagnosis and procedure (CPT-4) codes against lists of appropriate code combinations, Lang says. "It will either accept the ICD-9-CM or flash a warning saying this diagnosis does not meet guidelines."

If a physician has given a diagnosis that doesn’t match the selected procedure code, Comply will prompt the user to have the patient sign a waiver, which can be faxed or e-mailed to the physician’s office while the appointment is being scheduled, adds Nidal Kanadilo, a programmer for Tempus Software. "While the physician or the nurse is on the phone, [he or she] will see a printout of the waiver."

The software will accommodate an unlimited number of user-defined payer databases, allowing each hospital to match its exact payer mix, Lang says.

At Kettering Medical Center, if the physician’s order is noncompliant, a waiver is faxed to the physician’s office, along with the scheduling materials to be given to the patient. The system also generates an "exception log" that records each incidence of noncompliance. "It will eventually generate charts," Ezzeddine explains. "If the physician is again and again scheduling a particular exam that is not indicated, we will go back to the physician and say, What are you doing?’"

One of the hospital’s major concerns, he says, was ensuring that the scheduler would not be the one deciding whether to accept or decline a procedure. Another key issue was how the necessary information would make it all the way to the bill, Ezzeddine says. "When a patient has to sign a waiver, billing needs to know that, so it won’t bill the insurance company [or Medicare], because that would be double billing."

The information is sent to the billing department by way of the HL7 communication module, Encompass Connect, Lang says. This interfacing technology enables scheduling information, including CPT-4 and ICD-9-CM codes, to be shared with other systems such as billing or claims editing, he explains.

What billing receives, Kanadilo says, is a schedule information update message, which consists of fields for these pieces of data:

• patient;

• visit;

• schedule, including data and time of appointment;

• scheduled procedure, including CPT-4 codes;

• resources scheduled;

• diagnosis codes, including ICD-9-CM.

"If Comply issues a waiver to the patient, the procedure is flagged until the waiver is returned," Lang says. "If the patient forgets the waiver, the hospital can run a report and have an extra copy available before and when the patient arrives."

Once the waiver is returned to the hospital, the system is updated with those data, as well as whether the procedure was canceled, the patient should be billed directly, or a new diagnosis has been provided, he notes.

"The billing department is kept informed because Encompass automatically passes this information to the hospital billing system," he points out. "The billing department can simply review the pre-screened CPT-4/ICD-9-CM coding and issue the patient’s bill through the appropriate channel."

If a procedure is canceled or changed upon the patient’s arrival, the hospital cancels or reschedules it through Encompass, which automatically notifies other systems — such as billing — of the change.

Encompass Comply underwent beta testing at two client hospitals, including Kettering, and is scheduled to be on the market in the first quarter of 1999, Lang says. In addition to containing Comply, he adds, Encompass 7.0 has the following new features:

• multiple physician scheduling;

• patient alias names for security and privacy;

• Oracle database support in addition to the Advantage Database Server currently supported;

• new graphical user interface design;

• common object recognition broker architecture, which provides an independent platform for the scheduling engine.