Leverage PM To Prep For ICD-10

Edited by Jennifer Dennard, Health IT Outcomes

Pulmonary Associates is finding its Practice Management (PM) system instrumental in helping it prepare for ICD-10, all while keeping claims revenue flowing.

Pulmonary Associates is a 35-year-old private practice with five locations in the Las Vegas Valley area. Its 14 physicians and four advance-practice nurse practitioners provide care for patients who suffer from allergies, sleep disorders, and a variety of pulmonary conditions including asthma. Through its affiliation with 10 nearby hospitals, its staff also provides care to patients who are in intensive care or need ventilator support. Sonya Kohl, practice administrator, explains how the implementation of PM software has helped Pulmonary Associates offset reimbursement reductions and prepare for the transition to ICD-10.

Q: What revenue-cycle challenges caused you to seek out new PM software?

Kohl: The transition to ICD-10 codes next year has us taking a long, hard look at the current state of our revenue cycle. ICD-10 is going to require doctors to be very specific in their documentation. If our doctors don’t document to the highest level, we’re going to be lost financially.

We’re already feeling pressure from our payers regarding transition to more specific coding. They are already refusing to take not elsewhere classified (NEC) codes, which physicians use to indicate there is no separate specific code available to represent the condition documented. We’re potentially faced with getting no reimbursement for that initial visit because the insurance company will deem it as not being valid, even though it’s a very valid situation.

Q: How have you tried to manage these challenges?

Kohl: Everything is getting pushed back on the physician in the name of better documentation. We’ve tried to ease some of this burden internally by hiring a team of 12 coders. That team has been essential to conducting pre-audits, where we review notes beforehand. Most practices will tell you they conduct internal audits once a year or hire a consultant to come in and review 10 or 20 notes for accuracy. We decided almost a year ago to start reviewing every clinical note by hand. We want to make sure we capture valid charges and catch missed ones. This type of review helps us make our physicians aware of things they need to fix. Getting good documentation processes in place now will be critical to making the transition to ICD-10 next year.

We’re also putting our coders through ICD-10 boot camp in January 2014. We’ll conduct similar pre-audits when we come back from boot camp using the ICD-10 codes and show our physicians the difference in payment using ICD-10 versus ICD-9. We’re basically going to have to retrain our physicians on how to document. Short of putting a scribe with every single one of them, we’ll have to depend heavily on our e-MDs EHR and PM software to get us through this process.

Q: What role are PM technologies playing in this effort?

Kohl: They play a huge role. Without our e-MDs system, and even with basic software programs like Excel and QuickBooks, I would not know how much money is coming into the practice. By tying all of these technologies together, I have been able to put processes in place that allow me to see a holistic view of the practice’s revenue cycle, including the number of patients we see in a day and the number of charges that adds up to, the number of invoices that need to go out in a day, and the number of people it’s going to take to ensure those invoices are accurate.

Fortunately, our PM technologies have helped me to take the guesswork out of putting these pieces together. I use our e-MDs software, Gateway EDI eligibility and statement clearinghouse solutions, and Excel reports and QuickBooks to create custom spreadsheets that help me see how many claims are outstanding, how many have been processed, and how many checks are in the mail. We can actually see payer reimbursement and denial trends in Gateway, which lets me go back into e-MDs and make adjustments based on those findings.

These systems also have been instrumental in helping take some of the fear of the unknown out of our ICD-10 preparations. We’re in a situation that is very similar to what happened with the transition to 5010 and even Stage 1 Meaningful Use, where guidelines and regulations weren’t made available until the very last minute. It seems like the final ICD-10 code set won’t be available until just before the transition deadline, so we have to use technologies already in place to prepare.

Q: What specific benefits have you realized as a result of using these PM tools?

Kohl: Shortly after I started working at Pulmonary Associates, I realized we had about $90,000 in outstanding Medicaid payments. We figured out those checks had been lost in the mail and spent the next 90 days recovering them. Now that I have a system that allows me to tie data from our EHR, financial software, and clearinghouse into one nice spreadsheet, I know exactly where our money is at all times and have a very accurate idea of projected claims and reimbursements.

The time savings we’ve realized as a result of using e-MDs and Gateway have been extremely valuable. E-MDs is one of the few PM software companies that enable us to group our claims by payer, which comes in handy when one particular payer’s computers go down. Instead of having to resubmit an entire batch, which may include hundreds of claims to different payers, we can go into the e-MDs system and grab one particular payer batch and easily resubmit it. That feature prevents me from having to enter all that data again by hand.

Q: What strategies have you employed to make best use of these tools?

Kohl: Practices need to understand the impact ICD-10 will have on their business. Figure out now what it will take to run your business with these new codes and set goals for what claims have to go out and how much money needs to come in so that your doors can stay open.

There also has to be a sense of urgency. You can’t afford to take a wait-and-see approach. You’ve got to be proactive on many different levels, whether it’s documentation, accurate claims, timely payments, or staff training.

When it comes to running a billing department, you must start fixing things on the front end. Too many practices assume collections will catch claims mistakes. At that point, however, you’ve created a trickle-down effect that results in a backlog of claims. A practice must post in batches, make sure that mistakes are corrected at the beginning, and that everything is turned around in a timely manner. Don’t wait for somebody in the collections department to find a mistake 90 days later, because many insurance companies won’t give you more days than that to resubmit a claim.

If you’ve got a good clearinghouse and file your invoices in a timely manner, you can get an answer back on a claim in anywhere from 14 to 21 days. That still gives you 69 days to fix any problems and get it back out the door. But, if you’ve created a backlog in the collections department by pushing everything on them, they can’t come up to breathe, and everyone suffers as a result.

I’m also a big advocate of staff education. Billing is no longer a data-entry job. An educated staff can help turn around a denied claim quickly because they have been trained on the codes, know what to look for, and how to resolve the issue. You’ve got to use your resources, whether it’s the help button in your EHR, your ICD-10 codebook, or the reports in e-MDs. This is not the time to learn on the fly. You’ve got to start doing some prep work now.