In a matter of months, Naples (Florida) Community Healthcare System decreased its inpatient weekly discharged not final billed amount from more than $16 million to around $2 million.
Laurie Fiore, director of health information management at NCHS, explains the system's successes through the employment of five best practices for lowering DNFB amounts and accounts receivable days.
1. Ensure data is delivered to coders on time. "Everywhere I've worked, medical records and patient data not available or delivered to the health information management department in a timely fashion is a major factor in delaying final coding," says Ms. Fiore. "If you are working in a paper environment, work with the nursing department to ensure the breakdown of the medical records immediately after discharge so they can be delivered to the HIM department for scanning. The HIM department needs to get those records scanned and available for the coders within 24 hours of discharge. This means looking at your staffing schedule and adjusting it accordingly — ancillary departments must also understand their role in revenue cycle," she says.
When a coder cannot final code a record for any reason, those reasons should be documented, she says. "Coding managers should work the on hold list report daily to keep the uncoded dollars down. Additionally, HIM directors and coding managers need to work together to identify the top reasons for these delays," she says, and work with the appropriate departments to resolve the issues.
"Ideally, we want to touch that record just once," she says.
2. Improve collaboration, spend time on education. The HIM department has to develop a strong working relationship with the clinical staff that is based upon mutual respect and trust, says Ms. Fiore. "HIM directors and coding managers should meet with the medical staff regularly. Highlight two or three topics and emphasize the importance of timely response to physician queries and timely completion of medical records," she recommends. Physician assistants, as well as any residents or fellows, should be included in this training, she says.
3. Focus on high-revenue departments. Ms. Fiore advocates paying special attention to departments with high dollar services, such as outpatient infusion centers. "Because there are big dollars at stake in these centers, understanding appropriate documentation and code selection is essential" she says.
Ms. Fiore suggests auditing outpatient infusion center documentation, coding and charging. "Ongoing audits and education are essential. Educate the staff on how to determine initial services, sequential drug administration and the calculation of each additional hour of infusion time. Working with [the center's clinical staff] is important, or you're really going to have a lot of money tied up or denied, not to mention the potential compliance issues," she says
4. Assess your current coding staff. Take a close look at your coding staff and determine if they are consistently meeting quality and productivity standards. "Replacing coders is sometimes necessary but the preferable alternative is to help develop their skill level," she says. "Coding managers are spread so thin it is very difficult for them to spend the time necessary to sit with coders and provide one on one education, especially if you have coders working remotely."
5. Invest in technology. "Technology is expensive, but critical," says Ms. Fiore. "ICD-10 is going to significantly decrease coder productivity; some predict as much as 40 percent." Ms. Fiore sees technology as a worthwhile investment, as the alternative will be equally expensive. "There is a shortage of good coders now. Finding proficient ICD-10 coders to handle the transition in October 2014 will be difficult and they will come at a premium price. That is, if you can even find them," she says.
"Labor costs aside, the lost productivity is going to significantly impact accounts receivable; cash will be coming in the door slower and denials and DRG changes will be on the rise," says Ms. Fiore.
"If a hospital doesn't have a clinical documentation improvement program in place, now is a good time to start. I also highly recommend investing in computer-assisted coding technology in organizations that have a relatively robust electronic medical record," she says.
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