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When Baycare Health in Clearwater, FL, purchased medical necessity software for central scheduling, officials assumed the health system was good to go for screening physician orders for procedures that wouldn’t stand up to Medicare scrutiny.
But Baycare was far from set, says Mary Roberts, CCS, coding manager for ambulatory care service. Her mission changed to modifying the software from Tampa, FL-based Omega Systems, so it would become more user-friendly for schedulers and registrars.
The good news is that with those modifications in place — and with the decision to hire trained coders to handle the process — Baycare has dramatically reduced the amount of money it loses on procedures that Medicare won’t cover.
In January 2000, the health system was holding $933,000 worth of accounts because the procedures performed did not meet medical necessity, Roberts says. "We couldn’t bill anybody and we were trying to find a payable diagnosis." By September 2000, "we closed the month holding $354,000."
In October 2000, she continues, 1,949 tests were put through Omega, 154 failed the medical necessity screen and, after follow-up with the ordering physicians, 149 passed. That was a 97% success rate, Roberts points out, and patients signed advance beneficiary notices (ABNs) for the remaining five procedures.
The problem with the Omega software, she says, was that it was designed to be used in a physician’s office, where a limited number of codes are needed. For a specialty such as urology, for example, the codes are always the same, Roberts adds. "A diagnosis quick list pops up and it’s easy for the clerk to choose the right code."
Trying to use the software in central scheduling — where different disciplines call in for everything from magnetic resonance imaging to mammograms — was much more problematic, she says. Even though words of text, rather than codes, could be entered to determine whether diagnosis and procedure matched, that text needed to come almost directly from the coding book, often in language that even physicians don’t routinely use, Roberts points out.
For example, she explains, "carotid stenosis" is the term most people — including physicians — use for a condition that is called "narrowing of the precerebral artery" in the coding books, and thus the software program. Similarly, "Graves disease," the commonly used term, is identified as "thyroid toxicosis" in the software, she adds.
Roberts made some 300 modifications to the software — loading Baycare’s own symbols for the CPT codes into the system — to make it more user-friendly, she notes, and spent three weeks working with schedulers on the process. She also added user-friendly terms such as "kidney stones" to the text describing the diagnosis. That still didn’t do the trick, Roberts says.
"One diagnosis was colon cancer with bone metastasis,’ and the scheduler put in the code for colon cancer,’ she explains, "but needed the code for metastasis.’ I just could not get the schedulers and clerks to have the kind of familiarity they needed to have. We were putting 200 inquiries a day into Omega, but instead of a 95% success rate, we were getting an 85% success rate and we couldn’t move from that."
Even with the medical necessity software and her modifications, Roberts realized, the expertise of a trained coder was needed. "They know how a chart is coded, what a complete abdomen’ [scan] includes — they know how to interpret medical information," she adds. "Registrars and schedulers are not trained to do that."
Roberts made the decision to hire a professional coder and, as a result, she adds, Baycare is now "100% successful in its reimbursement coverage." Of the approximately 8% of the procedures that don’t initially meet medical necessity, Roberts explains, staff are able to get the additional information to ensure a match on 96% of those. For the remainder, patients are asked to sign ABNs, she says.
Her simplification of the software’s terminology has made the process easier even for the coder, Roberts notes. "She can do it more quickly."
The health system now tackles medical necessity with a compliance team made up of the coder, a compliance representative and another access representative, Roberts explains. The compliance rep faxes inquiries to physicians’ offices regarding tests that don’t meet medical necessity, asking for more information, she says. If there is no response, the compliance rep follows up with a telephone call asking for the physician’s notes.
"If [the compliance rep] still can’t reach the physician’s office, she calls the patients and tells them they will be responsible for paying for the test," Roberts adds.
The other access rep on the team looks at any back-end billing errors that turn up, tracks down any missing physician orders, and makes sure they match the information given over the telephone when the procedure was scheduled, she says.
"The compliance center is housed where the films are, so [the access rep] makes sure the reports [of procedures] are there," Roberts adds. "We have to look at the report before we bill to make sure the final impression is the same [as the initial diagnosis].
The latter is true, however, only for non-Medicare accounts, she points out, as Medicare does not allow for that reconciliation. "I’m in the process of [arguing] with them on that, trying to convince them that is the way coding is properly done," Roberts adds.
In preparation for going live with the Omega software in July 2000, some 10 or 12 people — including Roberts, the project manager, the education/process manager, access managers from all of Baycare’s sites, the vendor, and Baycare’s information systems team — met via a weekly telephone conference to work out the logistics and customize the program, she says. Despite the extensive modifications and the time invested, the effort has been well worth it, Roberts adds.
She points out, however, that "there are still monies we don’t get." Sometimes, the physician orders one exam, but after looking at the film — while the patient is still on the table — the radiologist says further examination is needed, Roberts says. "Maybe they first did an abdominal CAT scan, and now he wants to include the pelvis. That hasn’t been run through Omega."
Although Medicare authorizes some of those procedures retrospectively, some are not covered, she notes.
Instead of hiring new coders when Baycare brings its inpatient business under the Omega process, the compliance teams will expand their scope to take care of both the outpatient centers and the hospitals, says Martine Saber, CHAM, regional director of admitting for Baycare.
There is one compliance team in place at present, with another in the process of being formed, Roberts says. Although people will be added to the teams when they begin handling the coding for inpatients, she expects an eventual total of no more than three teams — one for each hospital group in the Baycare system.
Reports done to determine where most of Baycare’s medical necessity write-offs are occurring, Saber points out, have focused attention on the ED. "Physicians are ordering tests, but are not documenting why they’re ordering the tests, so we’re losing a lot of money."
So, along with moving inpatient coding to Omega, Saber, Roberts and the vendor will look at ways the software can be put to good use in the emergency department (ED), she adds. "We won’t be using it to obtain ABNs — there’s too fine a line concerning EMTALA requirements — but rather to help physicians document the tests they are ordering."
(Editor’s note: Look for a full discussion of Baycare’s use of Omega in the ED in the next issue of Hospital Access Management.)