How Technology Can Help Providers Get Paid and Common Challenges

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By Dawn Osborn, MHS, RHIA, CPC, MT | Nov 10, 2023

3 minute read MEDITECH| EHR/EMR| Blog

Traditionally, a Hospital Information System (HIS) is geared toward creating a patient medical record, placing orders for patient care, and ultimately, capturing revenue to support coding and billing. Historically, the HIS was geared toward capturing facility and technical revenue, and provider revenue was a bit of an after-thought. Even though this has improved greatly over the years, professional revenue capture faces unique challenges, regardless of the HIS. Let’s explore areas within your HIS that often affect the revenue stream and with a bit of investigation could reveal opportunities for improvement.

Capturing professional charges

Today, most HIS’s are advanced enough to support professional revenue capture much more easily. Several options work well, depending on the type of professional revenue being generated. Some systems have a direct 1:1 component of technical to professional revenue. For example, most Imaging systems will support posting a facility charge when the image is taken, as well as a professional charge when the image is read. Similarly, most laboratory information systems can drop a technical charge when a lab is resulted, as well as professional charge for the pathology component if desired.

“Automating” documentation driven charges

Documentation driven charges can be somewhat automated, too. Professional charges can be required, or even automated, when reports are created by the provider within the HIS. This would include Consults, Hospital Rounding, History and Physicians, Discharge Summaries, ED Visit Notes, Procedure Notes and Surgery Reports. However, these can prove a bit more challenging. For example, some providers dictate reports and those must be “abstract” coded or coding software may be used to generate proposed CPT codes. Ultimately, a professional coder may need to either assign, review, or choose an evaluation and management code or CPT code prior to a final claim being created.

Bridging the revenue gap between acute and ambulatory

In addition, many HIS vendors also offer an Ambulatory (AMB) or Provider module for hospital-based clinics or provider offices. These work in conjunction with the Acute HIS to create seamless delivery of care by supporting a uniform medical record and order-entry system. Professional coding and claims work a bit differently for providers as well. In professional coding, the diagnosis are assigned at the CPT/HCPCS level and the claim format is generally billed out on a 5010P/837P professional format (formerly called a 1500), rather than a 5010I/837I institutional format (formerly called a UB). Some HIS’s offer an embedded professional coding solution, while others use an interfaced solution with the encoder or a 3rd party system specific to professional coding and billing.

Capturing Relative Value Units (RVUs) for physician services

Another key consideration for providers is getting credit for their work within the HIS. They may need to book revenue differently, reporting not only by department and financial class but also by capturing relative value units (RVUs) for services provided. Providers may also be credentialed to perform more than one service, requiring their claims to differ based on their work location (whether they are working in the ED versus Clinic, etc.). With all those considerations, it’s no wonder why professional charge capture, coding and billing can be a challenge for what was traditionally a facility-driven revenue capture system. Knowing all options available within your current HIS and leveraging those options to their fullest extent ensures that a healthcare system is taking complete advantage of embedded solutions and thus maximizing their professional revenue stream.

What’s next?

If these challenges seem all too familiar but you’re not sure where to begin to make improvements, let’s talk.

With a background in healthcare operations and more than 30 years of experience in healthcare IT, CereCore brings the know-how and the bandwidth to healthcare organizations who are struggling with provider charge capture, concerned about revenue leaks, or needing advice on how to maximize IT solutions.

An EHR assessment is a good next step, and CereCore has a team of consultants who specialize in the following:

  • Revenue cycle, examining patient intake through final billing processes
  • Full clinical operations, reviewing processes for clinical services (including acute, critical access hospitals, outpatient and specialty services) configuration and systems workflow
  • Full ambulatory specialty, clinic and physician practice review, evaluating system setup and value optimization
  • General Financial applications, reviewing integrations and associated areas for operational improvements

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About the Author:
Dawn Osborn, MHS, RHIA, CPC, MT

Healthcare Information Technology Consultant, CereCore

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