Here’s how to cope with APC system
Unfortunately, ED managers might have heeded advice on how to restructure ED operations in response to the switch to ambulatory payment classifications (APCs) based on outdated information, says Caral Edelberg, CPC, CCS-P, president of Medical Management Resources, a Jacksonville, FL, emergency medicine coding and consulting firm specializing in financial reimbursement. The long-awaited regulations have now been published by the Health Care Financing Administration (HCFA) in Baltimore. "So now you can take action based on facts, not hysteria or misinformation," she says.
Here is some advice for maximizing your reimbursement under APCs:
1. Know which services are subject to APC payment methodology. Types of services subject to APC payment methodology include surgical procedures, radiology (including radiation therapy), clinic visits, ED visits, diagnostic services, other diagnostic tests, partial hospitalization for the mentally ill, surgical pathology, cancer chemotherapy, surgical supplies, and preventive services for healthy persons, notes Edelberg.
"In general, services included within the APC procedure groups will be bundled for payment, including observation," she says.
Types of services excluded from APC payment methodology include antigens, splints, strapping and casts, pneumococcal vaccines, hepatitis B vaccines, influenza vaccines, blood and blood products, immunosuppressive drugs following organ transplant, and certain high-cost drugs infrequently administered, says Edelberg.
2. Do your homework. Careful review of the regulations is necessary, urges Jeffrey Bettinger, MD, FACEP, member of the Dallas-based American College of Emergency Physicians’ reimbursement committee and co-chair of the Florida College of Emergency Physicians’ medical economics committee.
"I would advise ED managers to study the rule closely, speak with peers and consultants, and start drafting crosswalk criteria," he recommends.
3. Improve documentation. Investigate how information is recorded and processed into codes and charges for billing purposes, suggests Edelberg. "Physicians, nurses, and other ED staff should be working on improving documentation of services."
These are the key documentation areas you should focus on, she says:
— Perform both random and focused audits to identify those records in which documentation is deficient and nursing progress notes don’t support the level of service indicated in doctors’ orders and medical decision making.
— Identify records in which notes indicate that procedures may have been performed, but the type and extent of the procedure, as well as supplies and medications ordered, were not documented appropriately.
Although Medicare may bundle certain supplies and medications into the APC, others will be separately identifiable, notes Edelberg. "And for those other payers that do not bundle supplies and medication into the visit, you will want to itemize separately for them."
4. Develop an effective forum for communication between coders and ED staff, including physicians and nurses. Effective communication ensures that coding can be performed appropriately to best benefit the institution, Edelberg advises. Coders should be represented at meetings to discuss documentation and coding issues, she suggests. "ED staff should be notified of coding changes that may impact how documentation is required to be performed to ensure correct coding."
The coding department might want to highlight outstanding ED staff who document well to encourage others, she says. "Peer pressure helps! Doctor-to-doctor and nurse-to-nurse is generally the most effective means of communicating. So one person should be designated from each professional area [physician, nurse, radiologist, etc.] to carry the message, while working closely with either hospital or outside coders to better understand and improve documentation and communication."
5. Learn how payments and denials will be managed. Study the process of how payments and denials will be managed under the new system so you can communicate any necessary information to ED staff and coders, Edelberg advises. When payments are reviewed and/or posted, you should have a system to ensure the denial is consistent with payer policy, she explains.
ED managers should ask the business office the following questions:
— When charges for more than one service or procedure are billed, how are they reimbursed?
— Is reimbursement bundled or itemized and paid separately?
6. Don’t cut staff yet. Edelberg has been contacted by administrators who were advised by other consultants to cut full-time equivalent (FTE) positions across the board in preparation for APCs. "That is bad business, in my opinion, as we can pretty much guarantee a learning curve for medical records and the business office. That may demand additional FTEs to manage the transition properly, outsourcing to coding, or a better method of performing the billing function."
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