Breaking the code

Healthcare Financial Management, Dec, 2005 by Dennis Mitchell, Michael J. Saulich

It's a common challenge for healthcare organizations: improving the timeliness and accuracy of coding. For University Physician Associates of New Jersey, the difficulties of a poor payer mix and a high amount of charity care led the organization to implement a system that enables providers to document and submit professional charges at the point of care.

The system, electronic charge capture, is designed to drive appropriate, accurate, and timely coding. Electronic charge capture has resulted in significant financial and administrative benefits for UPA, adding $6 million in revenue per year to the organization and leading to a 55 percent decrease in time to patient billing.

The Road to Electronic Charge Capture

UPA is the faculty practice plan of The University of Medicine and Dentistry of New Jersey, the nation's largest health sciences university. The mission of UPA is to promote and foster the clinical activities of UMDNJ faculty. The resulting revenue is used to support educational programs at the university and to fund clinical and scientific research.

UPA provides healthcare services in 14 clinical areas and 30 medical specialties at nearly 70 sites across the state, including University Hospital of Newark, the state's largest hospital. UPA's 350 physicians bill for more than 500,000 patient visits per year, amounting to more than $325 million in charges.

But the organization has faced several financial challenges. In addition to its poor payer mix and high level of charity care, increased billing complexities have yielded higher denial rates. Tougher contractual terms also have led to declining levels of pay. Additionally, monitoring physician compliance with federal billing regulations strained UPA's finances, at an estimated cost of $1 million annually. In 2002, these issues led UPA to seek ways to enhance its revenue cycle by improving the accuracy and timeliness of professional charge capture and submission.

From the Back Room to the Exam Room

UPA quickly realized that to effectively deal with the myriad issues that the organization faced--specifically in regard to professional charge capture and submission--physicians would need not only to be involved in the process, but also to become the central focus of such efforts.

Initially, UPA held educational sessions with its medical staff to instruct physicians on proper coding practices. In one year alone, more than 200 sessions were held. The organization also increased the frequency of its prospective billing audits in an effort to improve billing compliance.

Although both strategies were helpful, UPA found that as long as it relied on a paper-based charge capture process, any process improvement initiatives would always function in a reactive mode. The real desire was to work proactively with physicians to head off potential billing and compliance issues.

To understand how UPA could affect coding in "real-time" as charges were being rendered, rather than days or even a week later, UPA consulted a number of coding compliance experts. After reviewing UPA's needs, these experts suggested point-of-care charge capture as the prime option to explore. UPA assessed the available applications and selected a mobile solution that could also provide front-end decision support and billing performance measurement over time. An ROI analysis performed by the vendor forecasted that this system would yield a 14 percent improvement in charge generation.

Gaining Buy-In-Early and Often

In September of 2002, an initial pilot group of 30 physicians was identified as the system's first users. Interestingly, these physicians were not particularly technology-savvy. They were instead chosen to reflect a cross-section of users to identify the full spectrum of potential issues that could result from implementing this new technology.

The next step to drive overall physician acceptance and adoption was to appoint the chief of UPA's orthopedic trauma service, Michael Sirkin, MD, as the project champion. Sirkin was charged with engaging a physician champion within each department who would then help secure the buy-in of colleagues by communicating the need for electronic charge capture as well as the anticipated benefits of this system. These departmental champions would also prove instrumental in the training process down the line, helping to answer questions, mitigate any concerns, and model system usage.

Prior to training, UPA's technical support staff collaborated with the vendor's interface engineering team to integrate the necessary scheduling data from UPA's two separate office and hospital scheduling systems. Another interface also was created to send charge data into the billing system. Eventually, all three feeds were tested and implemented, allowing for real-time data transfer to and from the charge capture application in a seamless manner.

Going Live--The Technology Litmus Test

When it was time for the pilot rollout, participating physicians were given handheld devices, purchased by UPA, to run the charge capture program. Each handheld device was tailored with custom locations based on where the physician practiced, and each location was populated with patient census data. As patients were seen over the course of a day, physicians would "tap" appropriate diagnosis and procedure codes into the patients' electronic charge records. The system would then compare entered charges against numerous billing and compliance regulations, including local medical review policies, Correct Coding Initiative edits, and Medicare guidelines, to confirm the appropriateness of the charges, and would alert the user to issues requiring attention.