Appoint an APG guru; the expertise pays off nicely
By Kate McComb
Medicare Reimbursement Analyst
Highline Community Hospital
Seattle
Question: Why is it a good idea to designate an in-house coordinator to oversee ambulatory patient groups (APGs), and how should we choose and train that person?
Answer: For many facilities, APGs are still so new they are foreign to many outpatient managers. Yet these individuals play a key role in the payment process due to the crucial coding and pricing information their departments supply to the business office.
It isn’t mandatory that a hospital designate an APG coordinator. But given how little is known about APGs and their impact on reimbursements, it is a good idea.
A likely candidate for the position is someone with a keen eye for detail and a hospital financial background. The individual should also be skilled in outpatient coding. Good communication skills with department heads and senior management also are important.
Coordinators are self-taught
There is no formal training program for coordinators. It is largely a self-taught position. Unfortunately, the knowledge is acquired mainly through trial and error and in daily discussions with payers, software vendors, and consultants, and by attending seminars sponsored by hospital associations and coding experts.
A strong familiarity with the APG Definitions Manual, Version 2.0 published by 3M Health Information Systems in Murray, UT, and other APG publications also is helpful.
An effective coordinator can be a valuable resource for a hospital in several ways:
• The coordinator can help clinical departments upgrade the coding and pricing information in their Chargemasters to bring the data in line with medical records and the business office. This is a key part of the coordinator’s job.
The process is extremely time-consuming and involves revising every CPT-4, HCPCS, and revenue code in the Chargemaster and updating the department’s pricing to a level that at least meets fully determined costs. If the coding and financial information for each patient visit aren’t correct, it becomes impossible to know off-hand whether the hospital is getting the right reimbursement.
• Serving as an information conduit between the hospital and payers is another important function. At Highline Community Hospital in Seattle, we devote a large part of the day to speaking with health plan representatives on the phone getting answers to questions such as why certain claims are being habitually underpaid or denied.
The problem is often rooted in an incorrect interpretation by the hospital of the payer’s policies concerning a bundling or consolidation of significant procedures. The process is educational, and ultimately, the hospital wins out because the lessons learned help improve the coding and billing systems.
• A good coordinator also can act as a liaison between medical records and the business office. At most hospitals, these two functions are kept separate. Conducting quality reviews of claims before they are billed and later comparing them to the final payment increases a hospital’s ability to manage its reimbursements.
But to function effectively, the hospital needs someone who can travel easily between health information management and patient accounts. Ideally, the coordinator should understand both medical record and patient accounts in order to spot problems in the billing process.
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