The Wilshire Group Blog

Home | The Wilshire Group Blog | Coding Alignment – System Capabilities & Design

Coding Alignment – System Capabilities & Design

In our Coding Alignment Part 1 earlier this week, we outlined the considerations for beginning the process of integrating your facility and professional coding workstreams/departments from an operational perspective. Now we would like to focus on system design and workflows.

Historically (and especially within the EHR world), there was no application or workflow that supported professional coding work streams; this was managed by routing “superbills” around an office for charge entry and later, charge review. There certainly hasn’t been the same technology available on the professional coding side to evoke a true encoder workflow, as hospital billing coding has had for years now.  

More organizations recognize that implementing or optimizing their Professional Billing workflows means there is much less manual charge entry and more charge review on an exception basis, as well as significant opportunity for efficient coding of procedures/surgeries.

Furthermore, advanced encoder systems now have the ability to leverage coding technology which allows one coder to simultaneously address (code) both facility and professional coding requirements. Often this technological consideration is the most compelling driver supporting operational alignment. Why wouldn’t organizations capitalize on coding efficiencies supported by robust technology? 

What does this look like from a system design perspective? With the end goal of more efficiency from both a staffing and workflow perspective, consider these first steps:

Optimization of PB Coding Workflow

  • Identify your “multiple touch” areas in the coding process; that is, service lines where both professional and facility coders are touching one account. These are often surgical and procedural areas.
    • Have you made a system decision on who drops the professional charges for these areas (providers or coders)?
    • If your physicians drop their own charges, what is your review process?
    • Have you provided professional coders access to a stand-alone encoder, allowing them to access appropriate regulatory coding and billing edits, avoiding rework and denials?
  • Are reports to review documentation readily available, quick to read and encompassing of all necessary information for coding charges and diagnoses without hunting & pecking through the medical record?
  • Do you have a workflow for your professional coders to query physicians in case clarification is needed?

Once you’ve considered the above, look at next steps for true alignment of your facility and professional coding workflows:

Alignment

  • Is there a way that you can avoid coding of procedural areas individually on both the professional and facility sides? Can you clone codes from hospital billing to professional billing (or vice versa, if you bill for the majority of your physicians)? You will still need to review all cloned codes due to the differences between professional and hospital coding rules, but this will still save time overall. This workflow can be a precursor to the workflows outlined below.
  • Is your coding software positioned to support alignment? Can you enact a workflow where professional coders are able to use the encoder with ADT information on accounts and deliver the charges and diagnoses back to your EHR? Think about the time saved if PB coders can view the documentation in a computer-assisted coding (CAC) context – this could be a game changer!
  • Surgical and Procedural: With appropriate training on both facility and professional coding rules, what opportunities do you have for one-touch coding? In an ideal world, this is an encoder that fires both sets of rules at the same time and can deliver soft-coded CPT’s for the facility side and hard-coded CPT’s for professional side to your EHR at the same time.

Further Thoughts

  • It’s important to note that disparity will still be required for some service lines – not all coding workstreams can be managed through a congruent workflow.
  • Specifically, for exception-based coding on the professional billing (PB) side for clinic visits – for those that are provider-based billing (PBB), you’ll pull your diagnoses for the hospital billing (HB) side from Simple Visit Coding, so this advanced workflow is not necessary.
  • Don’t expect PB coding or single touch to be as slick as HB coding – for example, since PB is not account-based, at this time, evoking the encoder from your EHR and physician query practices aren’t as inherent in the coding activity.
  • How can you combine query processes for accounts that have both an HB & PB component – is it possible to use your CDI department to query the provider once for questions from both sides of the house?
  • Technically, the way the codes will interface to your EHR will be different – think HL7 charge interface for PB as opposed to an application program interface on the HB side.

The above questions can be used to start thinking about this pivotal change in coding workflow and system design.

Our Health Information Management professionals are excited to help organizations clear their path to success in aligning coding operations, as well as system and workflow concerns.

Recognition is deserved for those facilities who have successfully aligned both coding practices through large-scale revenue cycle integration efforts, due to the complexity & sensitivity of the dependencies. Have a story or comment to share? Please do so below – we would love to hear from you!