Ensuring Data Integrity and Protecting Your Organization’s Bottom Line: Part I

Part I in this two-part series touches on ensuring data integrity and primarily focuses on the ambulatory environment. 

According to an American Medical Association (AMA) benchmark survey, the number of physicians employed by healthcare systems now exceed those remaining in private practice. Employed physicians made up 47.4 percent of all patient care doctors in 2018, while self-employed doctors represented 45.9 percent of the total. Seven percent are independent contractors. The survey also found that in 2018, 56.5 percent of physicians worked in practices with 10 or fewer physicians (compared to 61.4 percent in 2012), while the number working in a practice of 50 or more physicians grew.

So, what does this have to do with health information management (HIM)? This new segment of our employee population represents yet another opportunity for HIM to demonstrate its skill sets and leverage existing staff and processes for the betterment of the organization. How? Well, let’s discuss a few in this, the first in a series of articles.

• Denials Management and Higher Reimbursement: The comparative algorithms used by the MACs (Medicare Administrative Contractors) continue to closely monitor the consistency of codes submitted from each facility versus those submitted by the provider, for the same service, on the same date of service. When coding is done by two different employee groups, disparities are likely, and data integrity comes into question. When the coding submitted by the facility and provider differ, especially the procedural CPT codes, one claim or both are rejected, typically resulting in a request for additional documentation. Both the facility and the provider end up waiting 30, 60, or more days for the payor to review the documentation submitted and make a determination as to which claim will be paid and which one will be adjusted.

My Recommendation: Consolidate the coding of at least certain physician claims, if not all claims, in with the HIM coding team. With Medicare Advantage representing nearly four in ten (39 percent) of all Medicare beneficiaries in 2020 – 24.1 million out of 62.0 million Medicare beneficiaries overall – and 11.4 million enrolled in a Patient Protection and Affordable Care Act (PPACA) marketplace plan, the demand for high-quality coding for HCCs (hierarchical condition categories) is on the HIM doorstep. 

When I introduced the topic of HCCs on Talk-Ten-Tuesdays in 2016, it was a relatively unknown coding-focused reimbursement methodology to many in the facility coding world. As I mentioned in several of my talks about HCCs, this is a diagnosis-driven reimbursement methodology. ICD-10CM is in our sweet spot. Physicians don’t have the time to dig through the never-ending list of 72,600 codes to find the specific code to submit on a claim – and why should they? 

HIM needs to be the champion that gets the doctors out of the coding business and into the documentation business. I’d rather ask a physician to give us a bit more specificity in the diagnosis than waste their time scrolling down the endless list of codes in the electronic health record (EHR) dropdown. When it’s all said and done, our employed physician practices will have higher revenues coupled with data integrity across the hospital and the practice.

• Scanning Consistency and Timeliness: How long do you wait for your clinics to add a document to the EHR? Do some papers never get scanned? Do we even know? How often do we provide copies of the records to payors, attorneys and patients, only to find out that we have not given them all the documents because something didn’t get scanned in a timely fashion? Is there a risk there? Absolutely!

My Recommendations: TEFCA (The Trusted Exchange Framework and Common Agreement) was designed to ensure that an individual’s electronic health information is available when they need it, and it depends on participation from stakeholders across the healthcare ecosystem. If it’s not in the record, it won’t be available in the health information exchanges either. I certainly don’t want to be the unconscious patient for whom the ED doctor can’t access the list of medications being taken. 

However, of greater concern is the mandate for patient access to electronic health records. Effective April 2021, the federal government will require health organizations to share medical records with patients electronically, free of charge. This is part of the 21^st Century Cures Act, which touches on a number of areas, including the aforementioned HCCs, but for patient rights purposes. It mandates that consumers be able to read notes that recap a visit to the doctor’s office, as well as look at test results electronically. Much of this type of data is already available in your patient portals; however, I have several portals, and at least one of them has no physician notes whatsoever. But putting that aside, it’s just downright embarrassing to give a patient a copy of their record that has less documentation in it than what their attorney or payer received. 

So my recommendation is to centralize scanning in HIM, where the processes are fine-tuned. With the volume of paper dropping on the inpatient side of our business, supplementing the scanning team’s work with paper documentation from the ambulatory side makes sense. This is a function that should be staffed six or seven days per week, and one of the few functions remaining on-site, to ensure timely capture of documentation for patient care purposes. If need be, those in the clinics can scan a document that is urgently needed by the provider during the visit; however, alternatively, that document can be added to clipboard in the basket on the exam room door that continues to survive, regardless of EHR proliferation.

There are many other skills we have. They are just waiting for deployment in new opportunities that will expand the HIM footprint and benefit our organizations.

Programming Note: Listen to Rose Dunn report this story live today during Talk Ten Tuesdays, 10 a.m. Eastern.