Bundling of payments for services transfers much of the
financial risk of providing services from payors to providers and incentivizes
hospitals and radiology groups to provide services efficiently. Coders and
billers definitely play a role in helping a practice manage this risk and keep
its own house in order, explains Kathy Pride, RHIT, CPC, CCS-P, CPMA, senior
vice president of Coding and Documentation Services for Panacea Healthcare
In her presentation “Radiology Practices Work Smarter, Not
Harder” at the 2016 RBMA Radiology Summit, Pride explained that although
bundled codes have been around for quite some time now, many practice
administrators, hospital administrators and finance departments still tend to
look only at charges going out the door and not at what is actually submitted
“Years ago, what you had to tell the doctors was just do
your work, we will bill it out and you will get paid,” she said. “That is not
the case anymore.”
Supplies is a classic example. With Ambulatory Payment Codes
(APCs), the incentive to use more expensive supplies without medical need was
eliminated. Yet, Price said she still regularly runs into administrators,
managers or doctors who have met with a vendor and gotten the impression that a
supply that costs three times as much is fine to use because one can charge
three times as much.
“I have to make them understand that yes, you get to charge
three times as much, but in actuality, you are not making a dollar,” she said.
“You are just spending more money.”
Other places practices lose money when there is not
communication and education going back and forth between clinicians,
administrators and coders include procedures and services that are either written
off or down coded because of lack of medical necessity documentation. Charges
that get stuck in a billing que until they become so old they can no longer be
billed are also an issue.
“I talked to one radiology group and they said they had not
seen or talked to a coder in three years,” Price said. “I thought, either you
are an amazing documentation guy or they are just not telling you what is going
While administrators, practice managers, radiologist and
finance staff need not be coders, they should all have a handle on where their
money is and coders can help with this. Price recommends that coders keep the
lines of communication open and help in the following ways:
- Provide regular reports not just on what charges
are going out but what charges are getting paid.
- Look at how much money is being held in ques.
Understaffing, lack of training or too many edits stopping charges for review
can create backlogs. “If you go over the time limit to submit a charge, you
just did that study for free,” she said.
- Get reports on what is written off for lack of
medical necessity and track them back to see where there may be opportunities
to reduce that number. It is not uncommon to find that a particular protocol is
at the root of the issue and by simply making a change to the protocol, the
practice or hospital can save a lot of money in reduced write offs.