While clinical documentation is essential to capture a patient’s condition, it also supports another critical aspect of healthcare: reimbursement. Indeed, payers rely on highly specific clinical terminology, accurately mapped to standard administrative codes, to determine appropriate levels of reimbursement.
In our on-demand webinar, Undercoded & underpaid: Making it easier to document to optimize reimbursement, IMO experts discuss how imprecise coding can impact an organization’s bottom line and how an EHR-integrated solution can help simplify the process.
From the point of care to claims
To better understand how revenue cycle management within healthcare relies on accurate coding, one must begin at the point of care. When a healthcare service occurs, the provider completes clinical documentation describing their patient’s condition. Ideally, the clinical terminology used during that documentation is linked to the accurate primary and secondary standard codes required for claims, and all the appropriate charges are captured.
However, as the revenue cycle continues along to claims management, denials may occur if important secondary codes and Hierarchical Condition Categories (HCCs) are missing. This roadblock to payment then creates additional work for clinical administrators who must track down the missing codes, apply them to the documentation, and resubmit the claim.
How undercoding leaves an organization underpaid
While secondary codes may seem minor, they can dramatically impact payments. Consider a patient who is immunocompromised with COVID-19. As a provider documents this condition, they will likely see the primary ICD-10-CM code listed for each description.
However, by employing a third-party solution that automatically maps each description to the accurate secondary codes, providers can easily capture specificity in the EHR without adding to the burden of clinical documentation.
For example, the CMS HCC code associated with the above patient’s condition would be HCC47: Disorders of immunity. Yet, in the absence of a third-party integration designed to capture that code at the point of care, the potential for reimbursement can go down and the risk of a denied claim can go up.
|Without specificity||With specificity|
|No HCC||HCC47: Disorders of Immunity|
|Risk Adjustment Factor: 0||Risk Adjustment Factor: .664|
|RAF score difference: .664|
|Annual expected expenditure difference: $6,219|