Exceptional Coders | Innovative Technology

A new survey showed that just 7% of primary care practices cannot pay their bills, but the situation is still not ideal for these providers a year after COVID-19, as reported by RevCycleIntelligence.com.

The U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) issued a report last month that expressed vulnerability concerns in upcoding, coinciding with hospitals increasingly billing for inpatient stays at the highest severity level. The report found that the number of stays at the highest severity level, which is the most expensive one, increased almost 20 percent from FY 2014 through FY 2019, ultimately accounting for nearly half of all Medicare spending on inpatient hospital stays. Further, its findings saw the number of stays billed at each of the other severity levels decreased, while the average length of stay decreased for stays at the highest severity level.

2020 presented daunting challenges to the healthcare industry, not only in diagnosing and treating COVID-19 patients, but also in transforming a healthcare delivery system to modern needs. There were hyper-growth adoptions in telehealth as more providers and the public embraced technology for patient engagement. Remote workforce, which has been common for companies like Aviacode for years, became the norm for many, who had to learn new processes if they hadn't been doing remote work before. This was true for medical coders and healthcare RCM workers alike.

The Centers for Medicare & Medicaid Services (CMS) announced the 2021 Medicare Physician Fee Schedule Final Rule that implemented evaluation and management (E/M) CPT code revisions effective January 1, 2021. The E/M code changes increased the work relative value units (wRVUs). However, because all fee schedule changes are required by law to be budget neutral, CMS decreased the conversion factor (CF) used in the fee schedule, resulting in lower reimbursement for other services. Additionally, CMS introduced two new codes, which may result in a new coding audit focus. And telehealth resulting in more than 60 services being added were among some of the other changes in the 2,165 page final rule.

Coding audits provide insight into the process of coding itself according to ICD10Monitor's article entitled "Coding Audits: A Compliance Necessity". Although coding audits typically include the review and analysis of the medical record documentation and coding, the article also suggests that one should also review coding policies and procedures, as well as coding operational functions.

Providers are facing daunting challenges during the pandemic. Not only in keeping staff and patients safe and healthy, but also in keeping practices financially sound. During these times, an increasing number of organizations, especially those with shortages of qualified medical professionals or those with fluctuating patient volume, have seen revenue cycle outsourcing as a solution. Outsourcing can help identify and implement improvements for better revenue capture and collection. A recent RevCycleIntelligence.com article on "Best Practices When Outsourcing Revenue Cycle Management" underscores the opportunities that revenue cycle outsourcing can have during these pressing times.

A report from the U.S. Department of Health and Human Services' Office of Inspector General (OIG) earlier this month found improper physician coding of stroke patients who were transferred from traditional Medicare to Medicare Advantage, which led to overpayments of an estimated $14.4 million. The OIG found nearly all of the selected acute stroke diagnosis codes that physicians submitted to CMS under traditional Medicare that CMS later used to make payments to Medicare Advantage organizations didn't comply with federal requirements.

While hospital financial performance is starting to recover after experiencing historic lows at the start of the COVID-19 pandemic, providers still face a bumpy road ahead, according to experts at Kaufman Hall. Comparing July 2020 to June 2020, hospital operating margins increased 24 percent. Operating EBITDA margins also increased by 12 percent month-over-month and were 9 percent above budget without the financial aid despite falling by 5 percent year-over-year, the firm reported.

The U.S. Department of Health and Human Services Office of the Inspector General (OIG) recommended earlier this month that the U.S. Centers for Medicare & Medicaid Services (CMS) should recoup the portion of nearly $1 billion that was incorrectly paid to hospitals because of medical coding and billing errors involving severe malnutrition diagnosis codes in FYs 2016 and 2017.

Last month, the United States Court of Appeals for the Fifth Circuit affirmed a lower district court decision to dismiss a False Claims Act lawsuit brought against a Texas-based hospital system. The lawsuit by a data analytics firm accused the health system of fraudulently using secondary diagnosis codes to increase its revenues over a six year period.