Access will need to ask clinical questions
More specific information is needed
"Why do you need to know that?" Patient access employees can expect to hear this question often from patients, as a result of the switch to ICD-10.
"Leaders will need to inform staff that additional detail may need to be captured in order to assign a more granular code," says Jim Daley, director of IT risk and compliance for BlueCross BlueShield of South Carolina in Columbia and chairman of the Workgroup for Electronic Data Exchange (WEDI), a Reston, VA-based nonprofit organization which provides information on health information technology.
In addition to demographic information, patient access employees will need to ask more detailed clinical questions. If a patient injured a leg, for example, a registrar might need to ask which leg and how the injury occurred.
Patient access staff should be prepared to offer a simple explanation as to why this information is needed. Lisa Gallagher, vice president of technology solutions at the Healthcare Information Management Systems Society, suggests saying, "In order to get your bill paid, we need a little bit more information than we used to.'"
Gallagher recommends using patient satisfaction metrics to identify whether patients are upset by being asked clinical questions at the point of registration. "If you expect this to happen upfront, it needs to be a well-trained professional who takes on this role," she emphasizes.
Codes have more specificity
Patient access leaders themselves need a thorough understanding of the code set and why the clinical information is needed, Daley says.
"It is common for organizations to focus on the diagnosis codes, ICD-10-CM, but they must also address procedure codes, ICD-10-PCS," he adds.
There is more specificity in the new set of codes. "In order to get paid at the back end for an episode of care, you need proper documentation and the associated coding," Gallagher underscores. On the front of end of the process, patient access employees will need to provide enough information, using the new codes accurately, to avoid denied claims.
Gallagher says, "You have to understand how the coding system has changed, and what each individual plan is looking for to give approval on a payment."
Patient access leaders should have a conversation with each individual plan that they work with to find out what their process will be if insufficient information is submitted, she advises. "If you don't give them enough information, will there be a denial? Or will it be sent back for recoding?" asks Gallagher. "You can't assume all payers are going to do the same thing if there is a problem."
Sandra J. Wolfskill, FHFMA, director of healthcare finance policy for revenue cycle at the Healthcare Financial Management Association, says these questions need to be answered by payers:
- For pre-authorization processing: What level of diagnosis and procedure coding is required to authorize the scheduled service?
- For admission notification processing to payers: What level of specificity will be required?
"Find out what information you minimally need and what will happen if you don't have that," says Gallagher.