Presentation on theme: "Track x – xxx day – 0000-0000 Title: “Role of Medical Records in the Revenue Cycle” Session: 15 Mar 11 – 1630-1720."— Presentation transcript:
1Track x – xxx day –Title: “Role of Medical Records in the Revenue Cycle” Session: Mar 11 –
2ObjectivesOverview of the revenue cycleDefine key roles, components and performance measures of the revenue cycleProvide an understanding of the Medical Records role in the revenue cycle managementExplain key functions within Medical Records that impact the reimbursement processIdentify opportunities for performance improvementExplain the connection between Medical Records and Denial Management/Revenue Cycle TeamDiscuss best practices for revenue cycle management
3Revenue Cycle Definitions Sum earned measured in dollarsWhat MTF earnsAccounts ReceivableAccounts that have been billed but have not been paidA/R DaysDays of revenue in codingDays are counted from date of dischargeDefinitionsDischarged, not final billed (DFNB)Patients are discharged but bill is not sent out yetAlso known as “Unbilled Report”ChargesDescription of services and priceBill Hold Days“waiting period” that allows for the posting of charges, make corrections, or apply any additional diagnosis or procedure coding
4Overview of the Revenue Cycle What is the Revenue Cycle?All administrative and clinical functionsthat contribute to the capture,management and collection ofpatient service revenue (*HFMA)
5Overview of the Revenue Cycle Hospitals operate as a businessFacilities/Providers need to ensure payment is received for services renderedMoney collected is returned to MTFUsed for purchasing needed equipment, supplies and servicesPayrollNeed processes in place to collect reimbursementFront-end processesBack-end processes
6Overview of the Revenue Cycle You Schedule Dr’s Appt.Arrive at office & fill out Insurance formsStaff collect your basic demographicsDoctor performs examinationDocuments clinical information in your recordprovides treatmentYou receive your bill, pay, & leave officePhysician receives payment & money is deposited into his bank accountRevenue CycleBasics
8Overview of Revenue Cycle Key Players in Hospital Revenue CycleScheduling & RegistrationCase ManagementClinical Documentation/ Charge CaptureMedical RecordsDenial ManagementBilling/Collections
9Revenue Cycle Key Player Functions Registration/Admitting/SchedulingSchedulingInpatient/APVsPre-Registration (Demographics)Insurance VerificationCollection of signed DD From 2569Medical Record/Account NumberPre-authorization/CertificationObtaining ConsentsValidate Physician’s OrdersAdmit diagnosisCollection of co-paysUp-front collection
10Revenue Cycle Key Player Functions Clinical Documentation/Charge CaptureDocumentation of clinical servicesPhysiciansAllied Health ProfessionalsNursesCharge CaptureTimely and accurate chargesNote: Charge Master is not currently used in MHS
11Revenue Cycle Key Player Functions Case ManagementPre-CertificationProvide clinical informationLength of Stay approvalProvisional DRGDischarge PlanningMedical Necessity ReviewsDocumentation ReviewAdmit orderCorrect patient statusMonitor if patients meet Inpatient criteria
13Revenue Cycle Key Players Functions Patient Financial ServicesBillingClaim preparation after dischargeTracking outstanding accountsCurrent Inpatients (LOS)Accounts not coded post dischargeFinal bills on hold due to errorsCollecting/Payment PostingCustomer ServicePre-authorization/CertificationProceduresDenial Management
15Medical Records Role in Revenue Cycle Track x – xxx day –Medical Records Role in Revenue CycleCoordinated effort between Medical Records & Key PlayersTo Prevent loss of ReimbursementEnsuring accurate billing, andAccurate registration + correct coding = “clean bill”Ultimate Goal
16Medical Records Role in Revenue Cycle If your MTF does not have a Revenue Cycle TeamStart one or become part of the teamEducate the key playersBecome involved – be proactive!Medical Records has a wealth of contributions in functional expertiseLink between Registration & BillingCoding compliance subject matter expertsCase Mix analysis specialistDRG & APC expertiseMedical NecessityJoint Commission/Medicare/Medicare regulation expertsAppeals & Denials experience
17Revenue Cycle – Loss of Reimbursement Track x – xxx day –Revenue Cycle – Loss of ReimbursementCommon ErrorsMedical RecordsLack of documentationDocumentation does not support medical necessityInappropriate use of modifiersInvalid/outdated codesPatient RegistrationDuplicate NumbersNot checking previous encountersMisspelling of NameIncorrect Patient Type/StatusInpatient versus ObservationBad patient addressCase ManagementValidation of Patient TypeClinicals not provided for pre-certificationAccurate collection of patient demographics and financial data at scheduling and/or registration as well as timely charge capture and correct coding are key components of the revenue cycle.Failure to assign a correct MRN/account number results in creation of duplicate medical records & prevents the physician from reviewing pt’s history and/or test results which could lead to duplicate ordering of test and procedures.
18Medical Records Role in Revenue Cycle Track x – xxx day –Medical Records Role in Revenue CycleWhat can Medical Records do to assist in preventing these common errors?Verify date of birth and/or SSNCheck name spellingDates of serviceValidate correct patient typeEnsure medical necessity is metTrend recurrent errors and notify appropriate departmentEstablish a good working relationship with all departments involvedCommunication is the key!
19Medical Records Role in Revenue Cycle Track x – xxx day –Medical Records Role in Revenue CycleMedical Records holds one main key function in the reimbursement process:CodingIt is sometimes viewed as the only revenue cycle functionIf records are not coded MTF will not be reimbursedWorkload will not be capturedOther Medical Record functions are also importantAssembly and AnalysisFilingTranscriptionRelease of InformationProvision of recordsEveryone job is important!
20Medical Records Role in Revenue Cycle Indicators that impact billing timelinessRecord not received from unitIncomplete clinical documentationAmbiguous documentation necessitating physician queriesCompletion of assembly and analysis of the medical recordDelayed or unavailable dictated reports/transcription turn-around timeCoding BacklogLack of coding staffSystem down-time
21Medical Records Role in Revenue Cycle What can you do to manage these critical indicators?Perform tasks to ensure:Accuracy of the coding and completion timelinessUnbilled accounts are closely monitored byNumber of accounts/days post dischargeHigh dollar accountsReconcile admission & discharge reportsDocumentation is properly documented in the patient’s medical recordsProcessing of records post-discharge is on targetAccountability of all recordsBenchmark Performance
22Revenue Cycle Performance Measures Track x – xxx day –Revenue Cycle Performance MeasuresA/R DaysMaintain between less than 30DFNB (Discharged, not final billed)< 2 days beyond bill holdBill-Hold DaysBetween 3-4 (some facilities have up to 6 or 7)Accounts should be monitored for charge postingCoding Accuracy95% rateAt least one external auditCoding EducationCoding ProductivityAHIMA RecommendationInpatient 24 charts per dayED 120 charts per dayAPVs 40/dayStaff Turn-Over rateStable staffing < 10 % turnoversKeep staff happy
23Medical Records Role in Revenue Cycle Performance Improvement OpportunitiesAssembly & AnalysisAccountability & completion of medical recordEvaluate loose paperworkIdentify ways for improvementTranscriptionist turn-around timeTrack dictated report timeDecrease coding backlogEnforce productivity standardsPrioritize Records for codingMissing discharge recordsContinuous cycle for recovery of missing records
24Medical Records Role in Revenue Cycle Performance Improvement OpportunitiesRegistration ErrorsTrend/Track common errors and notify departmentDelinquency Rate/Timeliness of DocumentationDevelop strategies for obtaining physician signatures and completion of documentation requirementsEvaluate Staff Turn-over rateStaff RetentionEducate and train entire staff in the role medical records plays in the Revenue Cycle
25Medical Records Role in Revenue Cycle Since coding is a key component of the Revenue Cycle focus on this function to streamline processesCoding ProductivityUnbilled AccountsAudit records monthlyRecurring editsPerform focus auditsTrend physician queriesDischarge DispositionsCoding EducationPhysician Documentation – Utmost importance!!!Complete and legibleContinuous Process
26Medical Records Role in Revenue Cycle Impact of Documentation & Coding“If it was not documented – it was not done!”Prior to CMS implementation of the Prospective Payment System (PPS) impact was minimalCoding function was ensuring diagnoses and procedures were on claimAfter PPS was implemented the focus was more on capturing complexity of patient population and increasing reimbursementCoding became a critical functionDocumentation
27Medical Records Role in Revenue Cycle Impact of Documentation & CodingWhat is the importance of documentation?Documentation supports diagnoses and procedures coded on a claim/billDocumentation supports medical necessity for services renderedIf documentation is ambiguous account cannot be final billedPhysician must be queriedWhich leads to increase in Bill Hold DaysWhat steps can you takeConduct an assessment to determine your coding needs
28Medical Records Role in Revenue Cycle Impact of Documentation & CodingAssessment Checklist ExampleQueriesDone for all patient typesTracked and TrendedCoding QualityAre focus audits being conducted?Are monthly audits for Inpatient and Outpatient Records?Are internal & external audits done?Is coder quality at 95%?Case Mix IndexIs it being trended?Too high, too low?
29Medical Records Role in Revenue Cycle Implement a Clinical Documentation Improvement ProgramImproves coded dataLeads to better documentationProvide physician educationDecreases query backlogEnsures complianceImprove communication between physician and codersA CDI program means better documentation which leads to more accurate coding and less denials
30Medical Records Role in Denial Management Most denials can be prevented!Denied claims have direct impact on your MTFs bottom line – decrease in net revenueAffects everyoneUltimate GoalGenerate a “Clean Bill” and,Reimbursement is received“It takes a village”Direct communication and cooperation between all key players is the answer!Continuous monitoring and process improvements = reduction of denied claims
31Medical Records Role in Denial Management Categories of DenialsClinicalLack of pre-certification or length of stay authorizationLack of Medical NecessityTechnicalWrong code assignmentImproper modifiersIncorrect patient identificationDuplicate claimsDischarge disposition discrepancies
32Role of Medical Records in Denial Management What can you do to prevent denials?Participate in your MTFs denial management programIf one is not in already in placeSuggest to your chain that a program be startedEstablish a good working relationship with all key playersPatient Access/SchedulingAdmitting OfficeBilling OfficeCase ManagementMedical DirectorRecommend weekly or bi-weekly meetings
33Medical Records Role in Denial Management What can you do to prevent denials?Become familiar with payer policies and requirementsWork closely with Case ManagementEstablish a process for case management review of recordsThat are missing admit ordersThat have incorrect patient statusThat have wrong discharge dispositionParticipate in reviewing AHLTA templates to ensure codes are up-to-dateConduct focus auditsReconcile Coding Abstract Sheets with UB-92 or Form 1500
34Medical Records Role in Denial Management What can you do to prevent denials?Work closely with the billing departmentTo identify types of denial claimsReasons for denialsCreate a denial management databaseSuggest using AccessTrack and trend denials that are related to coding or medical records completion, for example:DRG or Coding errorsNot meeting medical necessityIncomplete provision of medical record copies
35Medical Records Role in Denial Management Appeal TipsEnlist the assistance of the Medical Director in writing/reviewing the appeal lettersProvide as much detail as possible to support your caseEnsure documentation reflects the codingAdd lab values, medicationsReference appropriate coding guidelinesAttach clinical documentation and other resources as necessary
36Medical Records Role in Denial Management Additional StrategiesAppoint a staff member dedicated to monitor Unbilled AccountsBecome very familiar with the Outpatient Prospective Payment System (OPPS)/OCE EditsInvalid DiagnosisWrong sexE-code as principalInvalid ProcedureContinuous education processProvide feedback to coders and providersEvaluate processes and implement process improvements
37Role of Medical Records in the Revenue Cycle It’s Everyone’s Responsibility!Admitting/SchedulingEnsuring all patient’s demographics and insurance information is accurateClinical Documentation/Charge CaptureEnsuring patient care is properly documented and charges are postedCase ManagementEnsuring admit orders are correct and admission criteria is metBilling OfficeEnsuring there are no duplicate claims
38Role of Medical Records in the Revenue Cycle Track x – xxx day –Role of Medical Records in the Revenue CycleMedical Records Best PracticesDocumentation is clear and conciseMedical Necessity is being metCapture of complication/co-morbiditiesCase Mix is trendedUnbilled Report is continuously being worked onBill Hold days are within specified guidelinesQuery process in placeMonitor ProductivityAudit and provide feedbackProvide coding educationBenchmark Performance
39Role of Medical Records in the Revenue Cycle Since Coding is the keyEnsure coding timelinessCoding compliance with official and MHS coding guidelinesImplement a CDI program to improve documentationCreate a physician newsletter to communicate coding changesDevelop a coding team newsletter to keep abreast of all new coding/policy changesFocus audits and provide feedback and educationRevenue Cycle is a continuous processFront-end to back end-endIt’s a never ending process!
40Role of Medical Records in the Revenue Cycle Questions
41Resources“Revenue Cycle Management Best Practices”Nadinia A. Davis, 2011APC Revenue Cycle: Tips for Success, Audio Seminar/Webinar, July 2009UBO Billing Manual, 2009“Getting the Most out of your Revenue Cycle”, Audio Seminar/Webinar, January 2009Revenue Cycle, Health Care Management Association, September 2010“Effective Denials Management”, Audio Seminar/Webinar, April 2009