Coordinating your facility's information systems is one of the most daunting but vital operational tasks. In Part One of this overview of coding and billing systems, I discussed some of the benefits offered by Admission/Discharge/Transfer, compliance, order/charge, electronic patient records, and billing software systems. We will now look at software systems you can use to submit clear claims, manage payer contracts, and organize data.
Editing SoftwareThere are software packages that contain coding and billing related edits based on official billing guidelines from Medicare and other third-party payers. The scope of data contained depends on the sophistication of the software package. For example, the Medicare Outpatient Code Editor (OCE) software contains information and "helpful hints" such as:
- invalid diagnosis codes;
- invalid CPT/HCPCS codes;
- age/sex/procedure code conflicts;
- invalid modifiers; and
- units of service out of range for the procedure codes.
The major benefit of editing software is that it can help coders head off reimbursement problems before they happen by helping the facility "clean up" its claims before they submit them. They increase the likelihood that the payer will deem the claim "clean" and process it in a timely manner.
If interfaced with billing system software, the editing software can suspend claims that contain one or more mistakes; in other words, disallow the claim from going to the payer with other, clean claims, and potentially hold up the processing of those claims. The suspension of the claim provides the facility an opportunity to address the problem, clean up the data on the claim and re-submit it.
Contract ManagementThis software allows the facility to plug in and review the financial components of their contracts with managed care companies and other capitated plans. Contract management software helps the facility sort out the details of the reimbursements from their various payers, enabling the facility to project "expected" payments due from managed care plans. This improves the chances of catching and correcting both underpayments and overpayments of reimbursement claims.
For example, suppose an ambulatory surgery center has a contract with USA Healthcare Services. The facility's contract stipulates that the ASC will receive a flat $700 for a bunion repair procedure. However, if the ASC's coder bills for CPT code 28293 (bunion repair with implant), the ASC will receive an additional $200 to cover the cost of the metatarsophalangeal implant used in the procedure. Thus, the facility knows that when they do an implant procedure, the 28293 CPT code should yield a $900, rather than a $700, reimbursement from USA Healthcare Services. The contract management software can be programmed to look for $900 reimbursement remittance statements from USA Healthcare Services on all 28293 codes submitted to the payer.
Report Writer SoftwareReport Writer software allows a facility to generate standard and ad-hoc reports based on specific data elements that are housed in one or more of the health information systems being used at the facility.
For example, an ambulatory surgery center may use the software to generate a report listing all CPT codes and ICD-9-CM diagnosis codes, charges, and reimbursements for each patient seen in August 2002. There is a multitude of ways these reports can be useful management tools. Not only can they help track financial data and examine the consistency of billing charges and reimbursements, they also can be used to examine clinical data, look at the mix of patients and compare statistics over a period of months or years.
Lolita M. Jones, RHIA, CCS (lolitamj@aol.com) has been a consultant for ambulatory surgery centers for over a decade.
