July 17, 2018

Don’t Fall Prey to ED Charge Capture & Coding Vendors

Alison Hovind

The modern Emergency Department is a crucial and fast-paced environment, providing care at high costs.  It is imperative to obtain full reimbursement of services, yet many EDs struggle to charge and code their accounts effectively.  As a result, vendors look to sell niche solutions (with hefty price tags), advertising advanced charging & coding capabilities.  For decades, reliance on vendors in this way was really “best practice” for hospitals and provided a reliable and meaningful return on investment.  In the context of the modern EMR however, individual vendors are no longer an effective strategy/cost to employ.  That doesn’t stop them from pitching to directors in your ED, Coding, and Revenue Cycle departments though, generally claiming to offer the following benefits:

  • Improved documentation quality
  • Increased coding accuracy
  • Increased revenue capture
  • Improved compliance & defensibility

Let’s look at each to see what the reality holds, and I’ll highlight reasons that selecting and paying for one of these niche solutions is likely a losing proposition for your organization.

Quality of Documentation

Every top EMR on the market, whether a niche product or integrated solution, should be claiming high documentation standards.  The big EMRs all get top ratings from KLAS, and if you have Epic, you’ve got the system that has been at the peak for 8 years running.  Today’s version of Epic’s ASAP module provides ready-to-use setup, including standardized diagnosis & procedure documentation templates, integrated decision support, and charge automation.  With many additional bells & whistles, and flexibility to meet state requirements, payor stipulations, and other needs, quality is nearly guaranteed if you are leveraging and using what the system offers.

Your EMR should be enabling your staff and guiding them to achieve high standards of documentation, but no single feature or program can guarantee it.  At the end of the day, the responsibility is with the individual, and quality will correlate directly with how they choose to use (or not use) system constraints & guiderails. If someone boasts about their product’s documentation quality, it should at least be spoken within this context.  And if you are finding that your system is not supporting and driving your staff’s documentation adequately, it may be time for some improvements, updates, and educational efforts that have been put off for too long.

Coding Accuracy

Coding accuracy is in all reality the big-ticket item vendors bank on today, citing that their proprietary or advanced coding architecture sets them apart.  However, at its core, each system is a set of rules and algorithms, so this is essentially a claim that one set of logic is superior to the rest.  And perhaps that would be valid if each system came pre-defined, rigid, and unchangeable, but that is certainly far from the case.

Looking at Epic again, we find the E&M charge calculator and coding assistance tools to be 100% configurable.  Also, included for use is both a shorthand method (for speed and efficiency in simpler scenarios) and a detailed, point-based system (for accuracy in more complicated scenarios).  Since a large portion of charges and coding can now be automated based on documentation and other EMR functions, staff should also have tools at their fingertips to review and modify the original documentation and corresponding charges when necessary.  In fact, assertions of subpar charge accuracy in Epic really can only trace their roots back to poor documentation, manual adjustments/errors, or mistakes with general billing configurations.  The cause is almost always a resource, and not the system itself.

Finally, the process of transitioning to Epic or any other major system should include a comparison of charts (~100), ensuring the accuracy of both automated charges and manually coded accounts to the historical outcomes.  The bottom line is that if there are concerns over charge accuracy and coding accuracy, your HIM director and revenue integrity resources must dive into any and all reasons why. Otherwise, you risk jumping on the bandwagon for another system and experiencing the same things.

Increased Revenue Capture

The potential for increased revenue is certainly real when switching to a new system.  However, it is almost entirely the result of going from outdated systems or manual/paper processes, to the new and improved.  If you were to transition between two modern & well-configured systems, the gains would inevitably be minimal.  Furthermore, the tools and efficiencies a new system provides tend to help most and boost revenue most in struggling areas, not in those already operating at a high level.  Ultimately, revenue resulting from system transitions is due to improved documentation, checks & balances, and reconciliation processes that become enabled.  There is no magic feature or algorithm any system has – if there was, everyone would be using it!

The integration and automation that modern EMRs like Epic provide also provide revenue increases in the form of time and resources.  With automation and accuracy going up, the amount of review needed goes down.  Sites that let their clinical staff and system processes post charges, even with a known accuracy rate of only 80%, free up their coding staff to focus on the remaining 20% and the more complicated accounts.  It also enables them to identify additional reimbursement opportunities, rather than trying to fly through accounts at high volume. So yes, transitioning from manual charge ticket processes or migrating from a 30-year old system is going to shore up revenue leakage and provide a boon to productivity.

Departmental gains at the clients we work with typically are in the 10-20% range.  It can be disappointing to know how much you’d let slip away, but also exciting to plug the holes, “gain” significant revenue, and start walking confidently in the direction of a better financial future.

Compliance & Defensibility

All EMRs and charging solutions should naturally comply with state and federal regulation and be configured based on industry and domain guidelines from CMS and ACEP.  Similarly, any solution that can’t provide on-demand reporting and queries for information, probably isn’t going to be a candidate for your needs in the first place.  For example, in Epic you will find both standard and customizable management screens to help with financial reconciliation and monitoring of your key metrics.  These tools and reports are invaluable for ongoing performance evaluation, as well as any periodic audits that take place. If your system cannot demonstrate compliance and defend your claims, you should first take a hard look at your people and processes before jumping to conclusions about the system.  In truth, the only significant value-add you get from one of the expensive niche vendors is access to their own dedicated coding and audit review resources.

How We Help

Do you already have one of these external vendors charging and coding your ED accounts?  Do you know how much it is costing you annually?  Are you aware of what you are missing out on by not leveraging your EMR integration?  What % of your ED volume is “treat & release” that you may not be recouping costs for?  Are you interested in learning more, or understanding how to convert fully to Epic ASAP?  Give us a call here at The Wilshire Group.  Talk with our experts and we’ll not only tell you what it will take, but we’ll also help you understand what other gains and opportunities you may have within reach.

And if you already have Epic ASAP or another up to date EMR system, don’t let one of the niche ED vendors try to sell you on their product and services.  Leverage what you already have and what you’ve already paid for.  Make sure you configure your ED and HIM modules to use the best features and automation available, and that your staff are performing at their peak and using the system to its full potential.

If you have concerns with your system, the state of your ED charges, or just want to seize the opportunity to create optimal charging and coding in Epic, reach out to us here at The Wilshire Group and let us help you get there.  We’ll be happy to offer free advice or partner with you in any way to help you make good decisions and lasting improvements, because we know that a little bit of focused improvement can go a long way, and an honest look at your people, processes, and system arrangements could save you millions.

Alison Hovind

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