Overview
The accuracy of your coding, and the revenue opportunities it presents, is too often an unexplored component of revenue cycle performance and an untapped organizational revenue opportunity.
There are a range of issues within and related to coding in provider organizations, with high impact to revenue and profitability. For example:
- Rules and guidelines change continuously, presenting opportunities for revenue to be realized or foregone.
- The road to optimal performance requires regular periodic support of your coding team.
- Current challenges include:
- Telehealth services;
Most providers have dramatically increased telehealth visit volume. As such, telehealth is an area of particular scrutiny by payers, and volatility in terms of coding guidelines and rules. Nevertheless, few providers have complemented this explosion of telehealth business with coding training or claims audits.
The risk/reward related to this will continue into the future, as CMS and individual commercial payer rules will continue to evolve over months, not years. In addition, telehealth is set to be a core element of the 2021 OIG workplan, introducing greater risk of fines and penalties.
- 2021 E&M guidelines;
The complete revamping of how E&M claims are to be coded, set to go into effect in 2021, provides another high leverage opportunity to appropriately code and bill for services. E&M codes represent, at a minimum, a significant percentage of revenue in surgical practices, a majority in cognitive specialties, and nearly all revenue in primary care practices. Getting this right, by practice, by provider and by encounter is critical.
The window of time to proactively get your in-house coding staff up to speed, coordinate and prioritize their efforts, conduct provider training, and have an audit plan in place to assure adoption of new knowledge will close January 1, 2021.
- Other longstanding issues remain inadequately addressed by many provider organizations. While ICD-10 has been the law of the land since 2015, most clients still have unrealized opportunity. Codes and rules continue to be amended annually. This all requires ongoing scrutiny to achieve continuous mastery.
- The expertise of your internal team, its level of training and certification, staffing level, what proportion of claims are reviewed, the algorithm in place to optimize the application and therefore effectiveness of reviews, how effectively and impactfully coding staff communicate to physicians – all these factors contribute to effectiveness and efficiency of your program.
- For staffing alone, some of the factors impacting performance include; What is the right level of coding staffing? How many coders are certified? How many are trained and/or capable to effectively communicate coding information with your physicians? At what level of coding does the return on investment in staffing begin to flatten?
Even organizations with high functioning coding teams will benefit from external expertise. The best partner will not simply offer core coding expertise, but also a broader understanding of how coding issues interface with revenue cycle, IT and clinical operations.
Culbert’s team of CPC trained and other professional consultants have deep industry experience and have worked broadly across one or more of these related disciplines, sharing with you a broader context of how to optimize your coding performance and integrate these functions seamlessly with other areas and professionals.
Culbert’s consultants are experienced with designing staffing models, workflows, efficiency analyses, myriad enterprise systems and demonstrating ROI.
We will help you determine the right priorities and best use of your financial and human resources to accurately code the highest proportion of claims and optimize your return on investment.
