October 29, 2007

Set to Rinse
By Selena Chavis
For The Record
Vol. 19 No. 22 P. 24

Maintaining clean claims is only one chore handled by HIM as it becomes more entrenched in the revenue cycle process.

When the HIM department at Parkview Health in Fort Wayne, Ind., decided to take charge of improving the revenue cycle, the results were right on the money. Within a few months of making major workflow changes, the organization was able to eliminate coding and editing delays that equaled nearly $1.5 million in revenue.

“Because HIM is intimately involved in the revenue cycle, you start to get to participate in these kinds of opportunities,” says Maria Stolze, RHIA, vice president of HIM at Parkview, a healthcare system encompassing eight inpatient facilities and more than 6,200 employees. “We [HIM] initiated the opportunity. I think that is what is unique about it.”

As the already complex state of today’s payer provisions continue to become more intricate, industry professionals are quick to say it’s no surprise revenue cycle management has become a major industry buzz word, especially since statistics reveal that many hospitals lose millions of dollars each year to claims denials and delays. And since it only takes one small registration, coding, or billing error to send a claim back down the pipeline to the provider, the role of HIM is expected to become increasingly more prominent.

Specifically, HIM impacts the midpoint of the revenue cycle, from the moment a physician documents care to the time that codes are submitted for billing. Still, throughout the entire process, missing details can affect HIM’s ability to code accurately and promptly, resulting in delayed or reduced payments, payment denials, and rework.

“The whole term revenue cycle management is a new term for HIM, but it’s something we have been involved with for a long time,” notes Lou Ann Wiedemann, MS, RHIA, manager of practice resources with the AHIMA. “It’s a great time for HIM to really take a step up. We have a unique opportunity to educate people and really promote our knowledge and skill set.”

The HIM profession has been evolving since day one, according to Margi Brown, RHIA, CCS, CCS-P, CPC, a senior consultant with DCBA, Inc. and a 25-year industry veteran. “It will be even more prevalent in the coming years,” she says, adding that HIM’s role needs to continue expanding to have more voice in mapping out effective revenue processes. “Their scope of skills is absolutely expanded. You are not just coding anymore.”

HIM Goes the Distance
To effectively identify ways to eliminate potential points of failure, as well as potential solutions, Stolze says Parkview had to realize that the revenue cycle was a process involving every hospital discipline. And since the revenue cycle reaches across many departments—from registration and clinical to HIM and finance—she says it’s often difficult to determine where the responsibility for revenue cycle lies.

“HIM is always watching to see how many uncoded records there are … so that HIM is not negatively impacting revenue,” Stolze says, adding that, typically, the role of HIM in the revenue cycle has been directed at coding accounts and managing that activity.

Leading the charge to reengineer Parkview’s revenue cycle management meant branching out to work more closely as a team with other departments. “Management of revenue cycles absolutely requires multidisciplinary participation,” Stolze says. “This was a major change for many departments, not just HIM. [We] had to embrace change because it was for the betterment of Parkview.”

Rita Bowen, MA, RHIA, CHPS, enterprise director of HIM services with Tennessee-based Erlanger Health System, concurs, noting that HIM has essentially become the “bridge between clinical and the business office” in the organization’s revenue cycle process. In fact, to stay on top of coding issues, she says it has meant an expanded skill set that is more refined to the clinical side for coders at the 800-bed, multicampus health system.

“Sometimes, it’s easier to teach the coder the clinical [aspects] than to teach clinical the coding skill,” she suggests, noting the ever-growing complex nature of the coding piece. “You have to work as a team with them.”

Comparing the complexity of the process to an octopus, Brown notes that it has many arms reaching “everyone in the hospital. On the outpatient and inpatient side for revenue cycle … all of the functions you have to uncover and learn … it’s just huge,” she says.

Bowen believes it’s critical for HIM to take a lead role in revenue cycle opportunities and changes. “It’s the coding piece that drives the revenue cycle in many ways,” she emphasizes. Offering an example of expanded roles, Bowen recalls that HIM at Erlanger was recently asked to walk the entire revenue cycle committee through the discharged not final billed (DNFB) report, which is often generated to provide a snapshot of the current state of affairs in healthcare organizations. “We are constantly monitoring [the DNFB report],” she says. “We may not be responsible for all the bill holes there, but we [HIM] manage it.”

Wiedemann says the best coding practices are found in HIM departments that don’t have tunnel vision and make it a point to gain an understanding of the entire revenue cycle process. It’s also about taking action, she says, referring to the need for information management professionals to do more than just measure coding accuracy.

“Be proactive—don’t wait for people to come to you,” she says. “Work with physicians, go to medical meetings … reach out to other departments.”

The Impact
The initiative at Parkview centered around new technology and new processes, Stolze says. Due to the organization’s multicampus environment and the complex rules governing outpatient prospective payments and medical necessity guidelines, the organization first targeted ambulatory services.

“There was nothing but opportunity to improve,” she says, recalling issues that continually surfaced over incomplete diagnoses, missed charges, and inefficient communication methods. With new technology provided by 3M software, as well as new guidelines and expectations for turnaround time, the organization was able to communicate needs in a more timely manner to other departments and identify problems earlier in the game.

Before the reengineering, Stolze says medical necessity edits were identified by patient accounting (PA) during the billing process. Then the process would involve medical necessity forms being faxed to various departments, many of which were already facing time constraints for other duties.

By redesigning the workflow so that coding identified the medical necessity edit before it reached PA, Parkview was able to reduce turnaround times from 22.4 calendar days to 5.2, representing 278 patient accounts. The workflow changes allowed the organization to improve the turnaround time for outpatient coding edits from 30.5 calendar days to 3.2.

“Part of the software was a communication tool that allows you to notify departments or physicians about needed information. The tool also has embedded information about edits,” Stolze says of the software’s ability to identify potential coding problems. “With the tools, we can send information to various departments and require a return within one business day.”

According to Stolze, the results were nearly immediate because the organization set a new expectation. “Previously, PA hadn’t set an expectation for getting information back to them,” she says.

Parkview’s interdisciplinary team considered a few options for how to roll out the reengineering process. According to Stolze, the organization opted for a phased approach to avoid the onslaught of too much change at once. “We knew if we pared it down, we would still get 80% of the return, and we would get it sooner,” she explains, acknowledging that initially, they still underestimated the learning curve. “You’re asking a group of people to assume knowledge they’ve never had before. We wouldn’t have seen return on investment if we tried to do it all at once.”

Expanding the Vision
According to Brown, most facilities “have some type of process [for] improving or reengineering their revenue cycle in place. But for those that do not, they need to start now.” She says it is a challenging and fun opportunity, but it has to be balanced with compliance concerns.

Wiedemann equates the need to reengineer revenue cycles to having an expanded vision. “Organizations [that have started this process] have identified that it’s not just how you code but whether you got paid. They really understand the big picture.”

Many experts believe the first step is to better equip the HIM department with more staff, resources, and skills. “There’s a dollar investment up front, but in the long run, it should actually save an organization money,” Brown says.

At Parkview, Stolze acknowledges that the transformation could not have been pulled off without a key ingredient. “I’ve had the benefit of having a project manager in my area,” she says. “I would not attempt anything that involves this much change without a project manager.”

Brown concurs, noting that “HIM is overwhelmed. You add another thing to their list, and it’s not going to get done. There has to be someone directing the initiative.”

Those who oversaw the Parkview project include the hospital information system director, project manager, coding manager, and coding compliance coordinator from HIM; a core technical team comprised of the 3M project manager, Parkview information systems analyst, 3M interface specialist, and an interface consultant; and other key organizational resources, including the finance manager, PA billing manager, and PA billing supervisor.

Along with dedicated staff, Wiedemann believes another key component to continued revenue cycle success rests in the ability of HIM professionals to avoid getting caught up in the day-to-day routine. “Departments need to be thinking about how things are going to change. They need to be thinking outside the box,” she says.

Brown agrees, referencing expectations that healthcare organizations will have to adopt and implement ICD-10-CM and ICD-10-PCSi classification code sets, rules, and guidelines as replacements for ICD-9-CM by 2011. “We need to have our ducks in a row,” she says.

— Selena Chavis is a Florida-based freelance journalist whose writing appears regularly in various trade and consumer publications covering everything from corporate and managerial topics to healthcare and travel.

HIM’s Bright Future
With current shortages in the coding profession and the expectation of expanding roles, many industry professionals believe HIM professionals have an unlimited future.

“There should be no such thing as unemployment in HIM,” says Margi Brown, RHIA, CCS, CCS-P, CPC, senior consultant with DCBA, Inc. “There are so many opportunities in the HIM field, and it is continuously growing into different arenas. It’s definitely a great field to be in. ... The scope of skills has absolutely expanded.”

In fact, a recent workforce study report completed by the AHIMA’s Foundation of Research and Education (FORE) cited numerous factors influencing the healthcare environment that have a direct impact on the HIM profession. “HIM professionals are increasingly becoming standard-setters for electronic health records; advocates for quality patient records and for patient access and utilization of personal health information; and data experts for collecting, interpreting, and analyzing health information,” the report suggests. “Within any given healthcare organization, HIM professionals are no longer centralized in one single department but rather are decentralized, applying their expertise across entire organizations. As a result of these expanding roles, there is a growing demand for skilled, trained HIM professionals throughout the healthcare industry.”

FORE identified nearly 40 different work settings where HIM professionals can now be found including the following:

• hospitals, physician offices and clinics, and skilled nursing facilities;

• educational institutions;

• government agencies;

• technology companies;

• insurance companies and health maintenance organizations; and

• consulting firms.

The report also detailed a growing range of positions that include roles in critical and influential jobs. Specializations include the following:

• enterprisewide data and information policy development;

• clinical data quality oversight;

• organizational privacy/security officer;

• document specialist responsible for monitoring accuracy and completeness of electronic and personal health records and other clinical databases;

• chief information officer;

• organizationwide clinical coding and revenue cycle management;

• data mining and analytics; and

• information access and disclosure specialist, including release of information under HIPAA.

— SC