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Capturing All the Charges
Health Data Management Magazine, October 2007
For example, Lahey Clinic in Burlington, Mass., estimates it's generating more than $1 million a year in additional revenue simply by using software to charge more accurately for all the services it provides. In addition, the organization has substantially improved its cash flow, slashing days in accounts receivable from more than 80 to about 34, says Cynthia Trapp, director of professional coding.
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Hospitals and group practices are taking widely varying approaches to automated charge capture. Some, like Lahey, are primarily relying on doctors to select the right codes, often equipping them with handheld devices. Others are implementing electronic health records systems that use natural language processing to automatically generate codes that later may be checked by professional coders.
Many provider organizations have focused their charge capture efforts in outpatient settings, where doctors routinely use a narrower set of codes. But others are automating professional and facility coding in inpatient settings.
But Does It Work?
Advocates for claims coding professionals, however, contend that the jury's still out on whether automated charge capture systems are reliable.
"More research needs to be done on how well these systems work," says Linda Kloss, CEO at the American Health Information Management Association, which represents coders and other health information professionals. AHIMA urges provider organizations to check the codes generated through automated charge capture to ensure accuracy before they send claims to payers.
"There's huge potential for technology to eliminate some of the more routine processing associated with coding," Kloss says. "It doesn't eliminate the need for knowledgeable coders. But it moves them into the role of data quality control."
An executive with the American Academy of Professional Coders, based in Salt Lake City, takes a harsher view.
"Doctors are not coders. There are rules around coding that are outside their responsibility. It's not the way they think," argues Sheri Bernard, vice president of member relations for the association.
Bernard advocates the use of "computer-assisted coding," software that coders use on the back-end to speed up the selection of codes for claims. She says automated charge capture systems can miss nuances, such as the use of modifiers to indicate a procedure was particularly complex.
Proponents of automated charge capture, however, contend that the systems enable physicians to easily select or verify accurate codes.
"Our physicians do a lot of the same tasks, so automated coding works very well for them," says Sarah Ligon, practice administrator at Old Harding Pediatric Associates, Nashville, Tenn. "Just because you have computers in the office does not make you robots. You can't be afraid of that. It's still humans making the decisions. How you use the software is the key."
Trapp of Lahey Clinic points out that many doctors are already accustomed to circling codes on paper when seeing patients. "We did audits of our existing coding practices, and this demonstrated to our doctors that they could code more properly with the software and generate some financial benefits," she says.
Truly Automated Coding
One of the more efficient ways to generate codes for billing is through a process some call "charge by documentation."
At Henry Ford Wyandotte (Mich.) hospital, physicians and nurses in the emergency department use an electronic records system that automatically generates codes as they build the record.
The clinicians use point-and-click clinical documentation templates that trigger codes in the ED PulseCheck system from Picis Inc., Wakefield, Mass. This results in far more consistent and complete coding, says Lois Vandercook, the hospital's EDIS coordinator. And the system paid for itself in six months by increasing revenue due to fewer missed charges, she says.
Physicians and nurses use a variety of devices, including Tablet PCs, computers on mobile carts and desktop PCs, to access the records system. "Everybody has their own preference, so we try to accommodate them," she says.
Vandercook created an electronic chargemaster, listing all potential charges related to the various clinical templates in the records system. "The very first time I did it, it took me two days," she says. Now, she updates the charges as necessary.
The records system, linked to the chargemaster, automatically generates billing codes for materials, such as IV bags, as well as diagnosis (ICD-9) and procedure (CPT) codes. It also assigns E&M (Evaluation and Management) Codes, the modifiers to CPT codes that indicate the complexity of the case on a scale of 1 to 5.
The codes are then reviewed by coders in the billing department before claims are submitted, Vandercook says. Although most physicians don't check the codes that are automatically generated, a few doctors take the time to double-check them, she adds.
Emergency department physicians were supportive of the electronic records effort, Vandercook says. "ED docs tend to be techies and like gadgets, so we had an easy time with them. The few doctors who had never used a computer were coached by the other doctors."
The software paid for itself in six months primarily through increased revenue as a result of more accurate charges, Vandercook says. Profitability of the emergency department increased more than $2.1 million from 2004 to 2006 thanks in part to the technology, she adds.
The ED PulseCheck system also can be used without the charge-by-documentation function. For example, physicians at George Washington University Hospital use the system to select codes from a list, says Neal Sikka, M.D., physician application manager. Coders then review the charts to make certain the codes are accurate.
Group Practice Strategies
In the group practice setting, early adopters are implementing electronic health records systems and integrating them with their practice management systems for billing. Some are taking the extra step of using automated charge capture to improve their cash flow.
Emerald Bay Center for Women's Health in South Lake Tahoe, Calif., is using a charge capture system that, like the system at Henry Ford Wyandotte, automatically generates codes based on documentation.
The clinic's one physician, Kelly Shanahan, M.D., and two physician's assistants use a records system from digiChart Inc., Nashville, Tenn.,accessed through the application service provider computing model. Using a tablet computer or a desktop PC, Shanahan uses templates to create clinical documentation.
"Then the logic behind the system presents codes based on the documentation," says Gay Horton, practice manager. The doctor confirms the code is correct, and then the information is transmitted to the ASP practice management system from AdvancedMD, Salt Lake City. The practice's billing specialist reviews the codes before submitting claims electronically through a clearinghouse.
"We are missing fewer charges because there are more checks and balances," Horton says. "In the AdvancedMD system, for example, if an appointment is made and nothing is charged for it, it flags the user."
The more efficient billing process has enabled the solo practice with two offices to cut its support staff to 8 from 12 while it increased its patient volume, Horton says.
Building a seamless interface between electronic records and practice management systems also has led to improved billing at Old Harding Pediatric Associates, an 11-physician practice in Nashville.
The practice's physicians use point-and-click documentation templates in its records software from Noteworthy Medical Systems Inc., Cleveland. Rather than selecting a code on a paper document, the doctors now pick codes from an online list within the records application, says Ligon, the practice administrator. When a physician orders a test, the codes associated with the test are automatically assigned in the Noteworthy system.
The practice's physicians preferred to use software to help them select codes themselves. "They didn't want a system that just automatically chose how to code things," Ligon says.
Later this year, the practice will use a new function in the Noteworthy software that offers automated suggestions for E&M codes, she adds.
Each evening, the codes from the Noteworthy system are automatically loaded into the practice management system from DST Health Solutions, Birmingham, Ala., where they're used for billing, Ligon says.
The pediatric practice has not measured how the automated coding process has affected its revenue. "But we know that the charge capture enables us to avoid missing charges, have fewer people in billing and print far fewer paper documents," Ligon says.
Reaping The Rewards
On the inpatient side, one hospital that's using automated charge capture is reaping 6.5% more charges per patient.
The 10 employed hospitalists at St. Elizabeth Medical Center in Edgewood, Ky., use Treo 700 smart phones from Palm Inc., Sunnyvale, Calif., to access demographic information and clinical tests results on the patients they're scheduled to visit each day, says Steve Slutzky, physician services representative for the medical center, which includes a 600-bed hospital plus two smaller hospitals. The phones are equipped with software from Thomson Healthcare MercuryMD, Durham, N.C., that displays a list of most frequently used claims codes that physicians select as they treat patients.
Many of the 140 other physicians at the hospital access the MercuryMD software using a variety of other hardware devices. By using the software to simplify the coding process, the average physician is trimming 20 minutes a day in time formerly wasted chasing paper or making phone calls, Slutzky says. The increase in charges per patient enabled the hospital to increase revenue in excess of the cost of the software in less than a year.
"Physicians get frustrated when they perform functions like hunting down a piece of paper," Slutzky says. "They want to spend time with the patient making a diagnosis. This software is an enabler for that. And it's a morale booster."
The hospital is touting its use of smart phones for accessing clinical data and performing charge capture as it recruits young physicians, he adds. "That's one of the 'soft' advantages of the system."
Don't Need an EHR
The lack of a complete electronic health record didn't stop St. Elizabeth Medical Center from proceeding with automated charge capture. Similarly, Lahey Clinic in Massachusetts sees auto-coding as a way to start down the path to further clinical automation.
Lahey, which includes a 300-bed hospital and a 450-physician group practice, equips most of its physicians with HP IPAQ PDAs from Hewlett-Packard Corp., Palo Alto, Calif., that are loaded with charge capture software from MedAptus.
Codes that physicians select from a shortcut list can be reviewed as necessary by the coding staff as well as clinicians. Each night, they are automatically loaded into a billing system.
Rather than focusing on entering charges for professional services, Lahey Clinic's coders now focus on other tasks, such as compliance audits and physician education, says Trapp, the director of professional coding. "The software also opened up the lines of communication between physicians and coders and created the ability for them to work together in real time," she explains.
"A physician's interest is in caring for the patient, not how the bill gets out the door," Trapp says. But once doctors understood how automated charge capture could yield long-term benefits for the organization, the physicians were supportive, she says.
Now that it has earned financial benefits from automated charge capture and has familiarized doctors with the use of mobile devices, the hospital is planning to purchase a full electronic medical records system, which it hopes to integrate with the coding system.
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