Get the best reimbursement by making sure claims are accurate
Home health coding experts a must for your staff
In the constant struggle to meet patient needs and still show a profit on your bottom line, you've cut costs and improved productivity. You've also looked at billing and collections for ways to improve cash flow, but have you considered a home health coding-focused staff or staff member who can make sure your claims are coded correctly the first time?
Coding for home health Medicare payments is not an easy task, points out Jane M. Gorwin, RN, BSN, a health care consultant with JG Solutions in Escondido, CA. With payments determined by information included on the OASIS document, it is critical to have a coding staff that understand home health care enough to recognize circumstances that qualify for additional codes that more accurately describe the patient's condition so that the agency can collect all of the payments due, she says.
"A home health coder should have two levels of knowledge," says Gorwin. "The coder should have the clinical knowledge to recognize the primary reason for home health care so the correct diagnosis is assigned, but he or she should also be able to recognize any other conditions that might increase the need for care or therapy so those codes can be properly applied," she says.
"A good coder should also have up-to-date knowledge of codes and changes in codes so that claims are complete and accurate," points out Gorwin. "The best coders are also the type of people who are always asking themselves if they've taken the codes to the most specific level possible," she adds. "You receive the best reimbursement when your codes present the most accurate picture of the patient's care," she explains.
Hospital-based agencies face the biggest challenge to coding claims correctly if their hospital insists that a central department handle all claims, admits Gorwin. "Coding for home health requires a different type of knowledge than coding for hospital services," she says. "A home health agency needs to own responsibility for coding its own claims," she says. Even if the hospital handles the final billing, the home health agency should do the initial coding and claim preparation, and the home health agency should handle the pre-bill audit, she suggests.
"We do have one person who specializes in coding our claims," says Barbara Beckman, RN, director of patient care services for Home Health and Hospice at Tri-City Medical Center in Vista, CA. "She is responsible for staying current on all coding changes and she understands home health care's clinical component enough that she can identify gaps that need to be completed to present an accurate picture of the patient's condition," she explains. "If she has any questions as she reviews the OASIS, she just calls the nurse to ask questions so that she can submit the most accurate claim that will result in the highest payment," she says.
Beckman's coding specialist doesn't have a clinical background, but she does have 10 years' experience working in a home care environment, auditing OASIS reports, and coding claims. "In addition to making sure she has access to coding publications and OASIS updates, we also support her efforts to attend seminars on coding," says Beckman.
The most economical seminars are on-line or audio conference programs, she points out. Not only are they more cost-effective, but also you don't have to backfill the employee's position while they are away, she adds.
Educate other staff members
Although Beckman has identified one person as the coding expert in her agency, her efforts to improve coding throughout the process include training her four case managers and her compliance officer. "It's impossible to train all of our field nurses to code claims, but if the staff members who handle the initial review of OASIS reports are familiar with codes and the details that can improve their accuracy, claims can be filed more quickly," she explains.
A clinical background isn't necessary for your coding specialist but there are some attributes your coder must possess to be successful, says Gorwin. "A good coder is well organized and detail oriented because coding is complicated and it is a challenge to stay up to date on constant changes in coding requirements," she explains. "Your coding expert should also be comfortable collaborating with others," she says.
"Even if the coder has a clinical background, she needs to respect job boundaries and recognize the staff nurse as the expert on the patient's condition," she adds. "Her questions to a staff nurse can clarify and focus a diagnosis but the coder needs to be able to ask the questions in a manner that doesn't put the nurse in a defensive position."
Even if you don't expect your field nurses to become coding experts, it is important to continuously educate them on correct diagnoses and accurate OASIS, says Beckman. "Cheat sheets, or software programs that offer all of the choices available, are helpful for some diagnoses, such as diabetes," she says. "If we make it easy for nurses to see the full range of detail that can be coded, it helps them be more specific on their own forms," she adds.
When your agency has one person who serves as the coding expert it is also easy to identify certain diagnoses or assessment items that create confusion. When a weak area is identified, use it as a topic to cover at case manager or nursing meetings, suggests Beckman. "At our regular staff meetings, we always include something related to OASIS," she says. "We'll talk about specific areas that need improvement and we'll use case studies," she explains. A case study would include a description of a patient's symptoms or complaints. Then nurses answer the question, "How would you diagnose this patient?"
If your agency is hospital-based and the hospital staff are still handling your coding, you need to quantify the financial benefits of a home health coding staff, says Gorwin. "Develop some scenarios that demonstrate the financial difference in a claim that is coded without a specific knowledge of home care to a claim that includes all of the details a home care claim should include," she says. In addition to showing a dollar difference, show how claim payments can be delayed if coded inappropriately and include information on the more complicated diagnoses, such as diabetes and neurological problems for which a simple addition of an extra code can greatly affect the payment, she adds.
"It takes a savvy hospital administrator to understand the need for a home care coding expert," admits Gorwin. She adds, "Who can better demonstrate the need than a savvy home care manager?"
Sources
For more information about home care coding staff, contact:
- Jane M. Gorwin RN, BSN, consultant, JG Solutions, 447 South Upas Street, Escondido, CA 92025. Phone: (760) 250-4558. E-mail: [email protected].
- Barbara Beckman RN, director of patient care services, Home Health and Hospice at Tri-City Medical Center, 2095 West Vista Way, Suite 220, Vista, CA 92083. Phone: (760) 940-5800. E-mail: [email protected].
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