By Dawn Osborn, MHS, RHIA, CPC, MT | Jul 22, 2022
Assuring that the correct provider charges are billed can be extremely challenging - despite last year’s updates to the Evaluation and Management coding criteria. Recent studies indicate that the perceived benefits of these new guidelines are yet to be realized. Creating workflow-based solutions to assist has proven especially difficult for information technology professionals. What are some of the complexities to consider? How can integrated solutions help support the varying needs for physician billing? Consider these provider billing challenges and how your healthcare organization can design and optimize systems to maintain revenue streams.
The variability of hospital billing structures
The complexity begins with the number of different contractual relationships healthcare organizations can have with their provider community.
These relationships and scenarios within hospitals and/or healthcare organizations can create a multitude of potential billing, coding and even documentation needs. The variety of scenarios within a single organization can require extremely complex workflows for accurate billing.
Add the varying types of codes that could be used for these services, E/M level codes, CPT procedural codes, HCPCS codes and you’ve added even more complexity to the matrix. Hospital charge capture, coding and claims generation commonly use encoders with inpatient/outpatient groupers in order to assist with encounter-based coding. Groupers do not normally include a physician coding module – that is usually an “add-on” module if it is even available from the encoder vendor. While many companies offer computer-assisted coding in the acute space or computer-assisted documentation that integrates with the coding processes, these technologies are still relatively new. Many of these solutions do not address the provider side, don’t launch at the right place within the provider documentation workflow or are cost prohibitive.
Different criteria for provider billing
Professional services provided to a patient as part of an inpatient stay can use different guidelines for determining the correct evaluation and management code than if that patient was seen in a hospital-based clinic, the emergency department and/or a provider’s office.
In addition, professional billing is submitted on different claim types and requires different claim field values than hospital and hospital clinic/department billing. These require additional maintenance and development in the chargemaster and claims modules.
Workflow examples: Contract changes
Here are several examples of the variation that can exist in who bills for provider services.
Although provider billing volume is often high, this workflow area is often overlooked because provider billing revenue is lower when compared to inpatient stays, surgery, or imaging. Reporting can be challenging, too, since provider needs and contracts vary, and healthcare entities may be required to report to both outside organizations and internally to the practice management group. As a result of these competing criteria, hospital information systems (HIS) have responded with a renewed focus on physician billing.
Working together for system and revenue stream optimization
In summary, as business and IT operations collaborate on how to solve billing challenges and address variances in provider billing, here are four key principles to focus on:
By understanding the differences between the provider and hospital coding, billing and IT needs, healthcare organizations can better plan and coordinate across departments to meet these variances. Better planning and coordination can lead to greater optimization for systems and revenue streams.
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