Payer and Provider Bridge the Gap to the Future

Is the Problem the Language of Coding or is the Problem the Rules Associated with Code Usage?

As in all relationships, the daily transactions between the provider and payer are complicated and require care. No one denies that each party needs the other’s respect and understanding to succeed. And while the communications are frustrating at times, the satisfaction of connecting in such a manner that all parties—especially the patient—benefit makes the effort worthwhile.
Coding Edge asked representatives from both sides of the business to discuss the dance between payers and providers. We wanted to know what makes each perspective different and how the two players work together. Here are their reactions:

The Provider’s Perspective on Coding

By Helene Stout
Providers use codes to describe what we do. They are told to do this very accurately and specifically. Payers use codes to execute a contractual benefit in the most cost effective way possible. On one side of the fence, we have specificity and line-by-line detail, and on the other side of the fence, we have bundling for cost effective execution of the premium dollar.
Problems We Both Face
Payers do not update their standard code sets as quickly as required of providers. This typically causes a rash of denials at the first-of-the-year affecting the provider’s overhead.
The sophistication with which we use ICD-9-CM code sets varies widely among both payers and providers.
Providers are required by some payers to code everything they do and verify or understand coding well enough to know they are doing it correctly without the advantage of sophisticated software assistance.
Payers use the CMS bundling guidelines and some degree of homegrown rules. Most have sophisticated software programs that audit and edit codes and are customizable to meet their budget constraints.
Unfortunately, sometimes it seems not much thought has been given to the complexities of some patients’ cases, forcing manual review and resubmissions.
A lack of clear, concise published payer guidelines not requiring nor allowing interpretation for the use of CPT® as it relates to billing, coding and reimbursement makes it more difficult to communicate.
The infamous Resource-Based Relative Value Scale (RBRVS) fee schedules and their units are designed to value the work and overhead of the code (service) with which they are associated. This methodology is widely used, however, the ongoing tweaking of the units continues to cause difficulty for planners on both sides of the fence. I would suspect that except for CMS many payers use a different year, quarter, and conversion factor or percentage of Medicare for each contracted provider. Likewise, every provider has a set of the same values for each payer.
Implementing conversion factor methodology by using a stable unit structure in addition to one consistent set of rules allows both the payer and provider to negotiate on only one plane instead of the many they now must consider. Stability in structure can reduce anxiety on both sides.
The million dollar question is who should make the rules? A consortium that combines expertise in business, codes and health care, but not someone who has too much to loose or gain? Does that exist?

The Provider’s Perspective on Coding

By Kevin B. Shields, CCS, CPC, CCS-P, CPC-H, CPC-P, RCC, CCP-P

Although reimbursement should never drive correct coding, the financial reality of health care practice today is that providers and their staffs must be mutually involved in optimization efforts for the revenue cycle. This includes and remains especially true for documentation improvement efforts. CMS and the third-party payers will certainly increase scrutiny to submitted claims for payment in the future. In such an environment, the coding and HIM staff posture themselves to make substantial and meaningful gains for their practice or facility, in terms of compliance, revenue and risk-reduction.

Coders play the key role by acting as an intermediary between their entity (facility, practice, provider) and external review forces. Coders represent internal enforcement of payer guidelines, accepted documentation standards and provide the necessary screening of a claim for appropriateness. By working so closely with the source document, the coder intimately understands the baseline for record-keeping at his or her place of employment. Coders, more so than other staff, face the steep challenge of basing practice-wide coding procedure within the body of work known as the medical record. Such knowledge can help benchmark improvement standards while carrying out QA maintenance functions. Not only can the coder identify deficiencies in the chart, but we can recommend future methods that prevent errors and substantiate billed service.
The point here is to encourage providers and facilities alike to undertake documentation analysis and improvement as we transition into pay for performance, MS-DRGs and other quality reporting. If it is not already, quality reporting will soon become an industry-wide mandate. As suggested, the atmosphere for change is upon us.
In that spirit, coding staff should request and move toward practices that promote the following:
Accurate, Timely, Clear, Reliable and Complete Documentation—This includes the indications or diagnoses supportive of service. Appropriate code assignment rests in the details, such as laterality or which clinicians were responsible for carrying out the service. Additional details in patient history, the successfulness of the rendered service and concise statements to the relationship between events or conditions help to “lock in” CPT® and ICD-9-CM code assignments. A chart with accurate, timely, clear, reliable and complete record-keeping is indisputable.
Open Communication with Clinicians—There must be a clinician query process or exchange. Often coders cannot offer a professional judgment when an ineffective dialogue prevents access to the wealth of information our providers hold. The imperative requires coders, their managers and compliance analysts to step up in-house reviews of individual and practice-wide clinical documentation. Frank conversations and assistive workshops should hone the reasonable standards to set for practitioners.
Sustainable, Effective Compliance Plans—Implementation of such efforts as raising standards for acceptable dictations assist in making the compliance program more than a static regulation, but a responsive, pro-active vehicle of change. Along the same lines, risk reduction and revenue building are actually the result of adherence to a solid compliance program. For instance, some areas of emerging concern with the widespread adoption of EMR are overly-templated documents and improperly applied copy-paste capabilities; both increase the business and liability risk to a practice, negatively impacting the substantiation of coded data. Additions to the existing compliance plan that forbid or discourage use of such “tools” head off any future scrutiny those items may receive from the payer side.
The combined goal of health care is the treatment of patients. All items mentioned support that ultimate idea and protect the interests of our employers along with the well-being of their patients.

The Payer’s Perspective on Coding

By Julia Croly, CPC
The evolution of an adversarial relationship waged between payers and providers clouds the fact that they share a common goal of maintaining patient health at a reasonable cost.
Three serious barriers have arisen in the era of managed care. Payers assumed more control over the care provided to the patients through concepts of “prior plan approval,” “covered services” and denials for services considered as “not medically necessary.” In response, providers have increasingly grown to view the payer as being too involved in the overall care of the patient.
Expectations on a provider by the payer include:

  • Maintaining a comprehensive medical record
  • Knowledge of coding guidelines and accurate coding for services rendered
  • Upholding obligations as outlined by the contract between the payer and provider

The medical record is a document of growing importance. At times it is necessary for the payer to request the medical record in order to determine appropriate claims payment, ensure contractual compliance or perform quality improvement activities. All aspects of patient care including information regarding the need for, result of and use of services must be legibly documented in the patient’s medical record. The medical record should chronologically document the patient medical history in sufficient detail to substantiate medically necessary services.
An important element in claims filing is the submission of the most current and accurate ICD-9-CM, CPT® and HCPCS Level II codes reflective of the services rendered as documented in the medical record. Contrary to popular belief of many providers, payers want claims to pass through their pre-processing edits so they can be effectively and accurately processed. Substantial frustration results for both parties when inaccurate data causes a claim to reject or suspend. Subsequent resubmission of the amended claim, increases time and personnel costs for both parties.
Payers continually review medical and payment policies to determine how actual practices align with national and coding billing guidelines established by the American Medical Association (AMA), the Centers for Medicare and Medicaid (CMS) and specialty societies. Payers follow Medicare’s Correct Coding Initiatives (CCI) to process claims. Many payers serve a broader population than Medicare so payers develop other payment policies.
The payer/provider relationship is one of mutual need and will dynamically benefit in a shift from conflict towards collaboration. Transforming this relationship through a cooperative effort will invoke change to address common issues. Caught up in the rigors of the process, especially in this ever evolving era of health care delivery, we often forget that both sides ultimately have the same goal … be able to affordably deliver quality health care.

The Payer’s Perspective on Coding

By Ginger D. Morrow, CPC, CPC-H

The common goal of delivering quality, affordable, health care is essential to both providers and payers if we are to ensure the sustainability of accessible health care environments. The relationship between providers and payers is becoming more universal and is on the same playing field with the standardization of coding concepts and claims submission requirements. Many payers have now recognized the importance of employing certified coders and have integrated them into roles traditionally given to nurses or IT personnel for claims review, system configuration and consultative roles such as audit and appeals. This recognition of certified coders has established more credibility for payers, as well as provided a better understanding of provider issues.

Another contribution to the successful provider/payer relationship is concise communication and education. Often the education is a two-way street, engaging both sides to better understand the common coding concepts, thus reducing the administrative burdens on both parties. Providers should have a good working knowledge of each payers’ contract content, stipulations, and schedules — this is as essential to the process of accounts management as coding is to claim reporting. This is the one area that providers can hone in on to provide more detailed understanding of payer processes, as well as educating staff how to best utilize the vast web resources made available by most payers. Be aware of payers’ published information, as this may dispel certain administrative grievances, such as code editing. For example, most payers publish their edits before implementation, provide rationale, and cite date applicability.
Peer review auditing is a valuable asset to provider’s submitting claims to various payers. Often physician patterns of treatment in particular circumstances influence coding applications more than the actual encounter documentation. This often happens when
practices utilize templates such as superbills. Superbills can be a very useful tool in an office setting; however, they often cause much confusion due to the variances of what is marked on the superbill versus what is actually documented in the medical record. Although these templates are often relied upon for code assignment and billed charges, they are usually not considered a part of the medical record. Payers do not recognize this template as a component for auditing records, and providers usually consider this a financial document and do not house it with the medical record.
The superbill, though very prevalent, can be very dangerous if not reviewed on a regular schedule and audited against what documentation exists for that encounter. This is especially true when dealing with E/M assignment and is often a sore point for providers if a payer reviews medical records and determines that the documentation is not adequate for charges billed. Providers can avoid those pitfalls by analyzing their superbill content and ensure ulitimate specificity correlating to documentation. These types of templates must be audited against medical record content for accuracy and audit feed-back provided to ensure compliant practices.
The bridge of communication between providers and payers is built through education. We must each do our part to ensure that the universal concepts are adhered to and work collaboratively to identify opportunities for improvement.

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