To survive PPS: Get it right the first time
Coding will become more important’
The latest word is that the Health Care Financing Administration (HCFA) still plans to implement a prospective payment system (PPS) for outpatients by July 2000, although there are proposals under consideration for phasing in the system to mitigate its financial effects on providers.
Before recessing for the holidays, Congress passed $17 billion worth of relief from the Balanced Budget Act of 1997. Included in the provisions is reversal of a 5.7% across-the-board cut in outpatient PPS payments that was to occur in the current fiscal year.
The change alone is worth at least $4 billion to health care institutions, according to the American Hospital Association.
It’s not certain at present exactly what role access managers will play in the new system, but for access staff involved in outpatient coding and/or billing, the impact is obvious, says Peter Kraus, systems liaison manager for patient financial services at Emory University Hospital in Atlanta. "Sophisticated coding skills will be required to maximize reimbursement," he says.
Ambulatory patient classifications (APCs) — similar to diagnosis-related groups (DRGs) for inpatients — will be the basis of the new PPS. "What makes APCs different from DRGs is the potential presence of multiple APCs per case, which affect reimbursement via discounting, etc.," he says. APCs are determined by the CPTs (procedure codes) assigned to a case, and reimbursement is determined by various weight and rate factors applied to each APC, Kraus adds.
"My understanding is that the caregiving facility is not required to come up with the APCs applicable to an account — Medicare can do that," he says. "But hospitals will want to do so in order to predict and maximize reimbursement, as well as to ensure the accuracy of their coding.
"Because APCs are being introduced to control federal dollars paid for outpatient services," Kraus suggests, "facilities may find it advantageous to revise the way they offer such services in order to legally gain the most — or lose the least — from the shrinking reimbursement pot."
The role access plays will become more clearly defined as APC particulars are revealed, Kraus adds. But, he emphasizes, "Access managers and staff should stay ahead of the educational curve in case operational or functional changes are warranted."
At Sibley Memorial Hospital in Washington, DC, patient accounting and medical records personnel are doing most of the planning for APCs, says Jeffrey J. Williamson, CHAM, admissions manager. "They have told me that we are going to be required to make sure the information we enter is as accurate as possible the first time around, particularly regarding patient diagnoses."
Because of this increased emphasis on coding accuracy, Williamson notes, the pressure will be on access personnel to make sure the information they collect from other sources is correct. "We’ll have to make sure that what the physicians’ offices and other departments in the hospital are giving us is accurate."
That likely means, he says, that registrars will no longer be able to accept "rule-outs" — tests ordered to rule out a condition such as pneumonia — as justification for a physician’s order. "They will have to include the symptoms [that support a particular procedure]."
Rule-outs certainly will not be allowed, confirms Dave Fee, product marketing manager with 3M Health Information Systems in Salt Lake City, which developed the APCs, and there will be other important ways the new system will affect access personnel.
"There are two areas that are very important that will be dealt with upfront," Fee says. "There are certain sets of services that HCFA will pay for only as inpatient services, and there is a certain set it won’t cover at all.
"The role of the access manager is to make sure when the patient comes in for these types of services, the service is provided in the appropriate setting — either inpatient or outpatient," he says. "If the service is not covered, [access personnel] must make sure the patient understands that and [the patient] authorizes the provision of that service anyway."
In the end, Fee notes, the final coding will drive payment. If the preliminary coding done by access isn’t correct, that will jeopardize payment, he says. "It’s the whole issue of making documentation complete and accurate from the beginning."
Although the emphasis on accuracy at the point of service is not new, Fee points out that the coding process is not as crucial now as it will be under the PPS. "Coding in general will become more important: making sure all those codes are correct and current and complete will determine the viability of the services the hospital provides."
A weak link anywhere, he adds, will cause the hospital to lose dollars it doesn’t have to lose.
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