October, 2016:

MACRA Basics- What you Need to Know to Get Started- Webinar November 16th 1:00-2:00 EST

Please join our Free Webinar on MACRA Basics- What you Need to Know to Get Started




EHR Capture of Outpatient Evaluation and Management Services

Electronic health records (EHRs) have now been implemented in the vast majority of physician practices in the United States. As a certified coder, auditor and physician educator I’ve been actively involved in this process for years.  Healthcare is without question evolutionary.  But the implementation of EHRs is one of healthcare’s greatest revolutions affecting both the clinical and business aspects of medicine.  As an example, let’s take a look at how EHR implementation has affected outpatient Evaluation and Management (E/M) services.

E/M documentation, coding, charge capture, audit and the related follow up education have all been deeply affected by the implementation of EHRs. Healthcare continues to shift away from inpatient to outpatient services and payment methodology continues to shift from fee-for-service to risk and quality of care based reimbursement.  Additionally, physician practices are being incorporated into facilities.  Given these circumstances it is important to appreciate history as we consider the future so that we are poised to address change effectively.

Not so long ago a physician would see a patient, document the encounter by hand-written note or dictation and enter procedure and diagnosis codes onto a hard-copy “superbill”. A qualified (hopefully!) medical coder reviewed documentation and physician coding for each encounter.  Ideally, coders and physicians collaborated to address any documentation and physician coding discrepancies and finally a compliant claim would be generated.

Today most physicians document E/M encounters and assign codes using EHRs. Most EHRs include a billing interface that generates claims automatically based on coding assigned by the physician. At best, a qualified coder spot checks for documentation and code assignment discrepancy, but the expectation is that physicians document comprehensively and assign codes accurately.  Of course, a well-run practice also has an audit schedule in place, with effective follow-up education, as part of its compliance plan.  Ideally coders and physicians work collaboratively toward compliance and revenue maximization but even the most robust audit schedule reviews only of fraction of encounters for which claims are generated.  Clearly, much is expected of physicians.  There is no longer a coder acting as a “filter” through which documentation and coding passed prior to claim submission.  For this reason it is imperative that physicians have a deep understanding of documentation/coding guidelines and the technological knowledge that allows them to use the EHR most effectively.

Most EHRs have tools that prompt physicians to capture E/M key components and their elements. However, E/M compliance and revenue maximization still requires that physicians:

  • Know the E/M guidelines
  • Understand that medical necessity must drive the level of E/M service
  • Know how to appropriately score E/M services and assign procedure codes
  • Know how to use the EHR effectively to document only accurate, applicable and meaningful content

Of course all but the last bullet were important considerations prior EHR implementation.

Another issue emerging related to outpatient E/M services is diagnosis coding. While accuracy is important, historically diagnosis code assignment for E/M services has not been a reimbursement consideration.  However as physician payment models shift from fee-for-service to risk and quality of care reimbursement, it is essential that documentation and coding include more robust information related to illness severity and comorbid conditions.  Of course the adoption of ICD-10 allows for capture of greater diagnostic detail but along with this detail come more complex code assignment guidelines.

Since the implementation of the Diagnosis Related Group (DRG) payment methodology for inpatient services in the 1980s, clinical documentation improvement (CDI) efforts have been established to optimize capture of illness severity and comorbidities.  One of the advantages to facilities incorporating physician practices is that these institutions have clinical documentation optimization experience.  Still, outpatient healthcare has its own unique set of guidelines that must be learned by CDI specialists and then taught to physicians.  It is also important to note that, while physicians are expected acquire documentation skills that optimize inpatient code assignment, they are not required to actually assign the codes.  As the importance of diagnosis code assignment increases for outpatient services it will be interesting to see where responsibility for code assignment falls.

Healthcare is continually evolving. The EHR itself influences some aspects of this evolution while assisting with other aspects of it.  Innovation and flexibility have always been and will remain key to a successful healthcare delivery system.


Restructuring Physician Compensation in a Value-Based World

access HIStalk article

The Current State of Telehealth in the U.S.-webinar October 21st 12:00-1:00 EDT

Refining your organizations’ telehealth strategy has never been so important. 60% of Health Care executives list telehealth as a top organizational priority while 74% of American consumers say that they would likely use it. Telehealth has the potential to be the next disruptive healthcare innovation.

Culbert Healthcare Solutions invites you to join Culbert’s CMO, Dr. Nancy Gagliano, for a FREE WEBINAR on Friday, October 21st 12:00 pm Eastern for an insightful look at the current state of Telehealth in the U.S. Before joining Culbert, Dr. Gagliano most recently served as Sr. VP of CVS Health and as CMO of MinuteClinic, CVS Caremark. Prior to this, she served as Sr. VP of Practice Improvement at Massachusetts General Hospital (MGH/Massachusetts General Physicians Organization (MGPO).


Translating EHR Training Into Improved Revenue Cycle Metrics

Technology continues to drive mankind forward in ways unheard of from when the great millennium occurred in 2000! Who would have thought that we would be tied to our smart phones, performing a myriad of functions that once took precious hours of our time? Now, we do online banking, book air travel, hotels, rental cars, and many other daily tasks regardless of where we are!

These same technological advances have, in so many ways, impacted the healthcare industry too. And, arguably, the largest invention has been the creation of the Electronic Health Record (EHR). So, it stands to reason that most of the healthcare institutions have either implemented, or are in the process of implementing the latest and greatest EHR system for clinicians to record, track and share critical medical record information regarding their patients.

The installation of EHR systems may run into the millions of dollars. Often, they are integrated, or interfaced with Billing Accounts Receivable (BAR) systems to provide the tools needed for submitting claims cleanly, and in a timely fashion, for prompt payment. After all, as the saying goes, it truly is all about the Benjamins; it is about healthcare institutions having the funds necessary to succeed and to carry out their Mission Statements.

So, if State of the Art EHR and Billing systems are in place to optimize patient care and outcomes, and if they are designed to bring in a steady stream of required cash to run the institution, how is it that so many healthcare institutions have less than desirable revenue cycle metrics to show for all of the financial investment in the implementation of an EHR system?

During the many system implementation projects that I have led across the country, the single most neglected component of a complex system implementation is End-User Training. Although institutions will invest millions today to ensure that they have the latest and greatest software available for its end-users, tomorrow (after the system installation) they will attempt to minimize costs with a meager training curriculum. In some cases, training is a minimal consideration at best, offering a series of online tutorials; in other cases, training may be a couple of hour sessions for a given application. Often, trainers are limited in their knowledge of the software, or even worse, have no operational background to marry operational tasks with the new system.

In particular, clinicians who ought to become experts on EHR software, are often given minimal instructions regarding the many bells and whistles of a system that contains many wonderful tools for precise, complex clinical data gathering. By the time clinicians grasp the basics on how the EHR works, they are, easily, overwhelmed by the new system and have little time or patience to understand that part of the patient’s record keeping entails the ordering or charging for services rendered. This is where the rubber hits the road, or in many cases, the tires skid along and never connect to the road!

Recently, I was asked to evaluate the revenue cycle performance for an institution that had implemented a new hospital billing and EHR system. The billing and EHR System were designed to interface seamlessly with an existing providers’ BAR system. Unfortunately, the implementation team did not perform a thorough assessment of existing tasks that included the charge entry process. Under the old charge entry process, providers would manually complete encounter forms, submit them to a coding unit (where validation and manual entry were performed) before going through the remainder of the revenue cycle process. Under the new system, provider orders (charge entry data) were generated from the new EHR application into charge work-queues for designated end-users to review.

The training offered to the clinicians who generated the orders (charges) was inadequate. It did not take into account that providers were used to having support staff (coders/billers) complete the charge entry process. As a result, providers didn’t understand how to:

  1. Open an encounter, enter supporting clinical documentation and close the encounter for the system to continue the path of sending those encounters into work queues for review
  2. Link critical, required documentation to orders
  3. Complete and send encounters without creating duplicate orders.

At the receiving end, the coders and billers were not adequately trained to work their designated charge router queues. The results:

  1. Aged accounts receivable over 90 days reached a whopping 30% of the total AR. Prior to the implementation, it was closer to 20%.
  2. Days in Accounts Receivable were around 40 days. Prior to the implementation, this metric hovered in the low-to-mid 30s range.

The moral of this story is: The Best Implementation fails without a proper assessment of current workflows in order to design an adequate training curriculum.  All stakeholders should be proactive, performing their due diligence, identifying the knowledge base required for a successful implementation, and developing a comprehensive training program to meet end-users and institutional needs.

Today, clinicians are being asked to perform many tasks that once were delegated to support staff. Let’s make sure we give them a fighting chance!