Overcoming Growing Pains Through Effective Hospital Compliance

Medical billing and coding of ambulatory services can be a whole new ballgame for hospitals and health systems focused on the inpatient side of care. But it is a game many organizations must quickly learn to adapt to the new healthcare environment.

Healthcare is heading to the ambulatory space. New care delivery and payment models emphasize the use of primary care and clinic services, while consumers in high-deductible health plans seek the most convenient care at the lowest possible costs.

These trends, and many others, are prompting hospitals and health systems to increasingly invest in ambulatory care providers and facilities. Organizations have already acquired approximately 8,000 physician practices between 2016 and  2018, and the deals are likely to continue as regulators and payers implement new policies aimed at keeping costs down.

But as hospitals and health systems bolster their ambulatory offerings, the organizations are facing a new host of auditing and compliance challenges. And these challenges are inevitably leading to missed charge capture, chargemaster errors, clinical documentation gaps, and other revenue integrity issues.

To avoid revenue integrity issues, hospitals and health systems expanding into the ambulator space should:

• Create a multidisciplinary team to lead auditing and compliance for the ambulatory setting

Auditing and compliance teams must be able to merge hospital outpatient and ambulatory billing and coding processes to capture the entirety of services now provided at the organization. Therefore, the multidisciplinary team should include leaders from health information management, coding, clinical documentation improvement, revenue cycle, legal, IT, denials management, and physician practices. The team should also meet on a regular basis to identify weaknesses and opportunities and develop strategies for addressing both.

• Conduct regular chargemaster and coding compliance reviews and maintenance

Hospitals and health systems should already engage in chargemaster cleanup and coding compliance reviews to ensure claim edits are up-to-date. But auditing and compliance teams now facing more ambulatory providers need to verify Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) are not only hardcoded into the chargemaster but are also regularly updated to reflect the health system’s continuum of care. Similarly, organizations will need to revamp and regularly monitor new risk areas in the ambulatory space, such as documentation of prior diagnostic tests, patient history, and ordering physician information.

• Implement technology to assist with ambulatory billing and coding

Technology has touched nearly every part of healthcare to improve quality and efficiency, and compliance is no different. Hospitals and health systems taking on new practices can leverage their EHRs, computer-assisted coding systems, and other tools to help auditing and compliance teams identify areas of weaknesses and push solutions to the appropriate staff or provider. Healthcare organizations using such technologies have realized tangible outcomes, including improved coding accuracy and productivity.

• Consider single-path coding

Hospital and physician medical billing and coding follow distinct processes. However, many hospitals and health systems have already merged the processes into one using a single-path coding approach. This approach streamlines billing and coding for all the services a hospital provides by having one coder work on the professional and facility aspects of a claim. Single-path coding does require a significant investment, especially on the technology and staffing sides. However, hospitals and health systems already using this approach have reported streamlined workflows, increased efficiencies, and improve charge capture.

• Promote communication across the care continuum

At the heart of every auditing and compliance program should be communication. From the point of registration to account resolution, every hand that touches a claim should be able to collaborate and communicate to ensure a clean claim is sent the first time. For expanding hospitals and health systems, getting physician practices on board is key. Physician practices should have a platform or space to communicate with centralized coders and billers and vice versa. This collaboration ensures timely identification of weaknesses and resolution, as well as ongoing education.

Skyrocketing healthcare costs, the shift to value-based care, and increased competition are necessitating hospitals and health systems to pay more attention to the ambulatory space. Physician practices, urgent care centers, and other ambulatory settings are meeting the demands of the new empowered consumer and offering care at a much lower cost.

But in order to thrive in this new environment, hospitals and health systems that once relied on inpatient services to succeed have to update their auditing and compliance programs to ensure accurate and complete ambulatory billing and coding.