Getting Paid for the Work You Do

Thursday, September 3, 2015 | Michelle Reese

Reimbursement for patient face-to-face professional services (evaluation and management) has traditionally been driven by volume and level of service. With the current shift to value-based reimbursement, providers must now understand how they are being measured and how the specificity and detail of their coding will be used in that measurement. Claim submission is all about the data, using numbers (CPT codes, ICD-9/ICD-10 codes) to “paint a picture” of the patient’s current disease state, describe the services performed, and request payment for that work. The accuracy of how you paint that picture may affect your revenue in the shift from volume to value.

Diagnosis Reporting

Billing the accurate level of service remains important and can have a significant impact on reimbursement; accurate evaluation and management diagnosis reporting is equally important. A reflection of the patient’s disease severity and acuity is documented via the ICD-9-CM (future ICD-10-CM) codes submitted for claims payment and must be supported by the documentation. Your ability to accomplish this accurately and with the level of granularity required will be used to risk stratify the severity of your patients’ disease. Because providers’ cost and quality are scored comparatively, diagnosis reporting now holds a significant meaning, as it can affect your value modifier score and, ultimately, directly affect your reimbursement

Electronic Health Record Challenge

The challenge to improve documentation (and subsequent billing) is, in many ways, hampered due to the one tool that was supposed to make life easier: the electronic health record (EHR). Many EHR systems have become enablers in a world where there are just too many “clicks” involved to get through the day. Anything that will save a click or two becomes the default; “copy and paste” has become prevalent. Those defaults and copy-pasting actions can lead to incorrect documentation and inaccurate billing.

Providers must place a renewed focus on diagnosis coding and documentation. Some helpful tips are:

• Develop a CDI (clinical documentation improvement) program at the ambulatory level. Diagnosis rules differ based on site of service (ie, inpatient versus outpatient).
• Combine diagnosis billing and education efforts with planned ICD-10 education. Specific and thorough documentation will support the added granularity of the new codes.
• Use the value modifier as an opportunity. Document well and bill accurately to paint a clear and well-defined picture, not a sloppy, confusing, or contradicting one. If costs are high, documentation will support this, and providers will not be an outlier to their peers.

This post was excerpted from Michelle Reese’s article in the July/August issue of Cardiac Interventions Today magazine. Click HERE to read the full article.