Set up a time line; it’ll help you gear up for APGs
[Editor’s note: Outpatient financial managers face important questions in preparing for ambulatory patient groups (APGs). Some of these include: How much time should we give ourselves in advance to prepare for implementation? What do we need to have in place? Who are the key support staff responsible for making APGs work? Consultant Cathy M. Idema, BSN, MPH, CHC, president of Health Systems Management Network in Chatham, NY, specializes in advising providers on how to reorganize their operations to achieve optimal clinical and financial performance. This month, Idema addresses the value of time lines in APG preparations.]
ORM: Why are setting time-lines important in planning for ambulatory patient groups (APGs)?
Idema: Administrators are usually surprised by the length of time and amount of energy it takes to get ready for APGs. Time-lines are essentially a schedule for meeting important objectives. If you have a full range of ambulatory services, including radiology, pathology, and physical therapy, the process can take up to nine months or longer.
The reason is that preparing for APGs is far more complicated than most people believe, partly because the ambulatory sector, unlike the inpatient setting, is a lot more complex from the financial management information perspective.
In the inpatient setting, the entire range of patient services is usually rendered in one or two locations. As they relate to coding and diagnosis related groups (DRGs), the services are documented at a single site, and therefore the information is easier to control. In the outpatient sector, the patient may be seen in two or more different unrelated locations within the facility. Charge data can and usually are generated in each of those locations.
Medical records department doesn’t code all
Complicating the matter is that at many outpatient facilities, the medical records department is often coding only some of the patient encounters. Significant other charges are recorded by clerical or other technical staff, which then are billed through the Chargemaster.
And for medical visits, the system requires the presence of an ICD-9-CM diagnosis code before it can complete the necessary APG assignment. These issues can greatly complicate the billing process under APGs.
ORM: Then how can management set up a realistic time line?
Idema: To a great extent, your time-line will be determined by your payer’s own implementation schedule. Medicare plans to implement APGs by a certain date. Therefore, you’ll have to plan backward from that date and make certain that you are ready ahead of that starting date.
[Editor’s note: The Health Care Financing Administration in Baltimore has announced that it plans to launch the Medicare outpatient prospective payment system for hospitals on Jan. 1, 1999.]
We usually advise providers to be fully prepared a month in advance. They should have their internal payment systems up and running for APGs by no later than Nov. 30, 1998. The additional time will allow plenty of time to test-run and evaluate your system’s effectiveness as the final implementation date draws near.
ORM: What should occur within a time line?
Idema: There are several issues for management to consider in gearing up for APGs. They are extremely important and can determine the facility’s success in adapting quickly and efficiently to the long-term demands of prospective payment. We usually advise providers to:
• Recognize that the preparation process is wholistic.
The decentralized nature of ambulatory care makes it essential that the multiple sites of service are properly coordinated and synchronized to ensure optimum information management and proper billing. For example, you must have policies in place to ensure that administrative personnel in each department are documenting charge data such as evaluation and management services codes correctly, uniformly, and promptly throughout the facility.
It’s a team effort, which to a large degree makes its members co-dependent. Establishing a time line motivates everyone to work together toward a common deadline in developing these protocols.
• Evaluate your existing operations.
Ask yourself questions such as:
1. How are admitting and registration functions currently structured? Are they centralized, or does each clinical department operate its own?
2. How does the charge data originate when the patient is seen in multiple clinical sites? Is it paper driven or electronically channeled into a centralized health information system?
3. Are the data coming together and accruing in a desirable way? Or is the staff working in isolation and with outdated, inaccurate clinical and financial data?
4. Are there quality controls at work in these locations? If not, what can you do to implement some?
5. What will APGs mean to you financially? What kind of reimbursements are you projecting to receive? And how should you manage your services under those financial constraints?
• Establish a dedicated APG steering committee.
The committee should be composed of management-level individuals who can oversee APG planning and implementation. It should be represented by registration, admitting, ancillary services, finance, information systems, medical records, and utilization management.
The committee’s responsibility will be to do the following:
Map out the areas for oversight and improvement, such as the training of data input personnel on APG procedures.
Create a comprehensive task list to ensure that key concerns such as integrating medical records and the facility’s Chargemaster are properly addressed.
Develop a flexible time line for meeting those objectives, and direct all departments to adhere to it.
Oversee developments within each department as preparations advance toward a deadline.
• Review your facility’s charge structure.
Your charge data must be current and encompass the full range of ambulatory services provided by individual clinical departments. The tendency runs high for outpatient data to be plagued with inaccuracies.
Clinical information on the outpatient side can easily become outdated through simple neglect. CPT-4 codes change annually. Until only recently, there has been a tendency by administrators to pay more attention to the inpatient side than the outpatient. Updating the Chargemaster is essential to proper billing.
• Make certain that your information systems are integrated and working toward the same goals.
APGs are designed to reflect all services that are rendered on an outpatient basis. In the outpatient setting, processing this information can involve multiple information systems within one hospital. Often, the process involves more than one facility.
Laboratories, pathology, pharmacy, and radiology often have their own individual billing systems. Determine whether each department is properly integrated in the central information system.
A review of claims and billing information can reveal how how well the data stream is moving from these departments into the centralized system. The facility’s paper documentation, including encounter forms and charge tickets, must also be properly linked to your information system.
• Review the role of support personnel in APG billing.
Some facilities have a centralized registration process. Others have personnel in each department. The quality of the patient data is essential to the APG billing process. Therefore, take the time to train and retrain personnel by emphasizing the importance of proper data collection and transfer.
They don’t have to receive doctoral training in APGs, but it’s helpful for them to understand why quality data entry is important and their role as professionals in proper reimbursements.
At the same time, don’t expect more from support staff than they should actually provide. They should not be making interpretive decisions or judgment calls regarding clinical services.
• Get your physicians involved.
Physicians are an important link between each of the clinical departments and the coding information that is transferred to the central billing system. Therefore, they should participate in the planning and development process. In fact, the clinical coding that is crucial to APG reimbursements begins with physicians at each clinic site. For this reason, physicians should have a thorough orientation regarding the importance of proper documentation and coding.
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