Don’t Leave Money on the Table. Conduct a Code Review.

Team of healthcare workers cooperating while using laptop on a meeting at medical clinic. They are wearing face masks due to coronavirus pandemic.

By Chris Ekrem and Tracey Schuessler

The popular business adage is true in healthcare as well: what gets measured, gets managed.  

As healthcare professionals serve patients with compassion and quality care, an essential component of measuring that care is accurate coding.  Whether you are a Critical Access Hospital providing a wide variety of multi-specialty services or a Federally Qualified Health Center providing a high volume of evaluation and management services, without up-to-date codes, proper documentation, and well-trained employees, you cannot be confident that you are charging correctly, complying with regulations, or getting a clear picture of the care you are providing your community. Regular code reviews are critical to keeping up with the constantly-changing codes/regulations and getting paid for everything you provided. 

What is a code review?

A code review reveals error rates, which new codes are missing from the chargemaster, and areas where employees need more education and improvement. We recommend reviewing codes quarterly and measuring a small sample of patients—about five to 10 percent—from across the board, including surgery, ER, inpatient, outpatients, etc.  From that sample, an examination of diagnostic codes, procedures, DRG accuracy and CPT-4 codes should reveal areas of error (as well as what is being done right). In addition, an analysis of the chargemaster is an important part of the review process to ensure that all charges are medically necessary.

What is the value of a code review?

Re-educate your staff.

With the industry-wide adjustments following the release of ICD-10’s completely new coding system, as well as new regulations announced in October and the annual update of CPT codes each January, hospital staff are constantly learning new codes and procedures. In addition, payers have updated allowable billing codes, and national and local coverage determinations must be considered.  This is an overwhelming amount of ever-changing information for providers to process.

While no one can ever completely know ahead of time all the new rules and regulations, it can be learned. Coding reviews help healthcare professionals to continue to strengthen their “coding muscles,” and give organizations the opportunity to re-educate their employees, ensuring they are equipped to code correctly and confidently, allowing them to keep their focus on caring for their patients. 

Avoid overcharging and undercharging for care.

Another major value-add of a code review is making sure you aren’t leaving money on the table. If you’re not coding properly, your reimbursement may be too high or too low. In fact, the U.S. Health and Human Services Office of the Inspector General (OIG) found that from 2014 to 2019, the number of hospital stays billed at the highest severity level increased almost 20%. 
Furthermore, nearly 30% of the inpatient stays at these hospitals lasted a notably short time in light of the high severity level, a pattern which the OIG flagged as an indicator of possible upcoding.

Upcoding can result in compliance issues or Medicare takebacks, to name just a few potential consequences.  For example, one Tennessee home health provider paid $25 million to the United States and the state of Tennessee to settle allegations that it upcoded home health billings to Medicare and Medicaid, according to Phillips & Cohen. 

Having someone who is independent, neutral, and objective conduct a review will catch any upcoding or down-coding, as well as indicate that your organization is doing its due diligence and protect your facility.

Celebrate progress.

For all the importance of catching coding errors, another thing coding reviews do is tell you what you’re doing right.  It is important to look for opportunities to grow as an organization, but it’s also helpful to know the areas that are excelling and shouldn’t be changed.  Often, reviews and audits have a negative connotation among hospital staff and leadership, but a coding review is a great opportunity for positive reinforcement.  Having clear indicators of what is working well can be a real morale booster, and contributes to a culture of constant improvement and confidence that they can learn new codes and regulations and get them right. 

The bottom line: We believe strongly in the effectiveness and importance of regular coding reviews, and we urge you to find a company you can trust and get this service done! 

A code review allows your organization to be agile and thoughtful in adapting to coding changes, rather than undergo the stress of constantly playing regulatory catch-up.  Code reviews provide a major value for hospitals and health systems and are good for revenue cycle management, obtaining accurate reimbursement, discovering processes that are working well, educating staff, identifying coding blind spots, boosting employee morale, and ultimately helping organizations to accurately measure the care they are providing their communities.  

About EqualizeRCM

At EqualizeRCM, we routinely work with Community Health providers to audit or perform their coding.  We have 10 years of coding review experience, certification in auditing/inpatient coding/outpatient coding, strict adherence to coding best practice guidelines, and available individualized education to physicians to target any potential blind spots that are coding or compliance related.  

EqualizeRCM are experts in billing and coding for Critical Access Hospitals (CAHs), community hospitals, Federally Qualified Health Centers (FQHCs), urgent care, cardiology, physician practices, medical groups, Rural Health Clinics (RHCs), ambulatory surgery centers (ASCs), dental, ophthalmology, optometry, urology, autism, cancer centers, hospice, and wound care. 

Learn more at EqualizeRCM.com.