Jumpstart Your Journey in Revenue Integrity

Contributing to the financial health of your organization comes in many forms.

Revenue integrity (RI) has become common language in the healthcare profession. Whether you know it as a department name, job title, or initiative, it refers to providing patients with a fair and accurate bill while also ensuring coding accuracy and avoiding revenue loss in healthcare. The RI team acts as a liaison between finance and clinical care, usually reporting to the revenue or finance division of an organization. The typical RI structure touches multiple parts of revenue cycle management (RCM), including chargemaster creation, fee schedule creation, charge capture, charge/coding edits related to charges, process improvements, analysis for denial trends, and audits.

Revenue integrity jobs can range from entry level to leadership, with certification and experience in a healthcare environment, such as patient access, scheduling, clinical areas, reception, billing, nursing, or coding, usually preferred. Positions that fall under the RI umbrella can include charge representative, charge specialist, analyst, charge description master (chargemaster), auditor, coder, coordinator, consultant, supervisor, manager, director, clinical documentation improvement (CDI) specialist, and nurse, among others.

Let’s look at the components of revenue integrity and how they may affect your career path.

The Importance of the Chargemaster

The work of revenue integrity may be different across organizations depending on how the revenue cycle work is divided, but it universally involves the creation of a list of applicable charges in a database. Within this database, chargeable procedures, services, pharmaceuticals, devices, and supplies are represented by CPT® or HCPCS Level II codes, when applicable, a Uniform Biller (UB-04 revenue code), and the prices that will be charged to patients. When a CPT®/HCPCS Level II code is built into a specific chargemaster list, the code is described as “hard coded.” When the charge is set up to include a description and price, but the applicable code is added by the coder, it’s said to be “soft coded.”

It’s important that only the chargeable components of care are built into the chargemaster and that it’s configured to reflect the most up-to-date codes, charging regulations, and pricing. The determination of chargeable versus nonchargeable is based on the Centers for Medicare & Medicaid Services (CMS) Provider Reimbursement Manual 15-1, IOM Publication 100-02 and the Medicare Benefit Policy Manual, Chapter 1, Section 40. Using these resources, the chargemaster coordinator knows that the gloves clinicians wear during care are not separately chargeable because they are routine, inherent to care, and in the personal protective equipment category, which is non-chargeable.

A chargemaster coordinator monitors code changes throughout the year and updates the list as needed to ensure that all charges generating a CPT® or HCPCS Level II code are accurate. Each code has a status indicator that identifies how that code will be paid. These indicators allow the chargemaster coordinator to identify the codes with pass-through payments, which are paid outside of or in addition to other reimbursement programs.

Pricing

Pricing is a major part of the chargemaster coordinator’s or analyst’s job because an organization’s pricing must be defendable, align with the market, and most of all cover the cost of providing care. When a provider or organization charges less than the allowable reimbursement amounts, this is a contributing factor to revenue loss. Each chargemaster line item should have a markup from the acquisition cost of the item or the cost of providing the service. CMS regulations do not dictate what an allowable price should be, just that there should be an established charge structure applied uniformly. The price charged is different than the revenue received due to payer contract terms or flat-fee payment programs.

When a patient receives a service or supply that has been deemed chargeable, has supporting medical necessity, and is built into the chargemaster, the charge needs to be captured and applied to that patient’s account. When care or an item is provided but not captured, this can be a major source of revenue loss. A robust revenue integrity program with multiple layers of charge capture checking performed by credentialed staff who understand coding concepts and charging rules helps to increase accuracy and prevent revenue loss.

Charge Capture Methods

The revenue integrity team can capture charges and their associated codes through a variety of methods. Harnessing automation within the electronic health record (EHR) involves setup within the system but nets the greatest level of accuracy. This automatic charging can originate from documentation, results of a test, or other means. Interfaced charging occurs when a separate software program interfaces with the EHR and sends the charge.

Some organizations subscribe to charge capture software to help ensure its charges are accurate. Manual charge capture methods involve a user manually entering a charge at the time the care is provided or later after it’s discovered to be missing. Many organizations hire entry level applicants to start with charge entry. Reconciling the charges and associated codes is a critical component in identifying opportunities for correcting issues and ensuring accuracy. The credentialed positions doing this type of work are typically charge capture specialists, analysts, nurse auditors, and other professionals with titles that require knowledge of codes, charging rules, and critical thinking.

A Team Effort

For a full RI initiative, those with skills in all areas of RCM are needed to ensure the financial health of an organization.

Documentation

It’s important that every charge is supported by clinical documentation. Some revenue integrity teams have outpatient clinical documentation improvement divisions that focus on assessing and improving the clinician documentation. If details of the care that was provided are missing, the applicable codes or charges for a patient’s care cannot be applied and becomes a source of revenue loss. The CDI staff needs to have knowledge of codes, documentation standards, and charging, and is usually made up of coders, analysts, and nurses. These staff members can also be involved in providing guidance and training to providers.

Verifying documentation and then assessing the need for appropriate modifiers related to the charge codes can also fall under the scope of work for RI positions. National Correct Coding Initiative (NCCI) edits, including procedure-to-procedure (PTP) edits and medically unlikely edits (MUE) need the eye of trained and competent staff for accuracy. When charges and their associated codes are inaccurate, or the modifiers are inappropriately appended, it can cause coding and billing inaccuracies, which can lead to denied claims.

Auditing

Auditing is an essential part of ensuring accurate revenue. Coding, nurse auditors, and charge auditors contribute to identifying potential issues in the chargemaster and charge capture practices to ensure accurate charging. Many auditors have routine audit checks but also get involved with government or payer audits. The Office of Inspector General publishes a workplan that can guide auditors when selecting areas for review.

Denials

When a claim is denied, it’s important to assess whether the denial was preventable. Revenue integrity staff can use their knowledge of codes and charging regulations to analyze denials related to the chargemaster. They can also help appeal the denied claims or correct the root cause of the denial to prevent future denials. It’s important to use data of denial trends to identify root cause, problem areas, or denials that are not valid and need to be addressed with the payer.

Data Analytics

Data analytics help a revenue integrity team to understand issues by finding trends within larger-scale data anomalies. Reports that detail individual department or user charge practices can help to identify training needs, process improvement, or system update requirements. Having medical coding knowledge helps with understanding what charges and codes should go together. Gross revenue tracking, late charges, and the quantity of certain charges are examples of the types of data that RI data analysts track. From there, other revenue integrity team members can help to address the findings and fix root causes.

Are You On Board?

A robust revenue integrity department, in conjunction with other areas of the RCM cycle and clinical operations, will instill accuracy and accountability across your entire healthcare organization. Credentialed coding and billing professionals with communication, collaboration, analysis, and coding skills make perfect candidates to work in the realm of charge capture.

Resources:

CMS IOM Pub. 102, Medicare Benefits Policy, ch. 1

CMS The Provider Reimbursement Manual – Part 1

CMS IOM 100-02

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Jennifer Lavoie

Jennifer Lavoie, RN, CPC, is a member of AAPC’s National Advisory Board and works as the director of revenue integrity at Rush University Medical Center in Chicago, Illinois. Her work of bridging clinical care to revenue integrity to provide fair and accurate billing to each patient, while funding the mission of healthcare, has spanned multiple health systems, software providers, and consulting. Lavoie has a degree in corporate communications in addition to her nursing degree and AAPC certification.

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