CASE STUDY

Optimized Reimbursement with Top-Level Coding Services for a Major Medical Business Organization

Entering the market as a physician billing company in 1981, our client quickly expanded their focus to include a wide range of practice management functions that encompassed operations, facilities management, human resources, and revenue cycle management. Based in Augusta, Georgia, the client provides services throughout Georgia and South Carolina.

In 2015, the client engaged Infinx to provide coding services for five of their large radiology groups with terms that included a 24- to 48-hour turnaround time and exemplary quality and accuracy. The scope of coding expertise focused on radiology and wound care and included:

  • Diagnostic radiology
  • Interventional radiology, including vascular & non-vascular services
  • Wound care, including Evaluation & Management coding and coding denials processing

Addressing Concerns With Processing

The client wanted a one-stop solution for their growing medical coding business where they would use a trusted third-party partner to process, code, and prepare to submit claims from five industry-leading specialty client groups with some of the following concerns:

  • PET Scans — As an advanced diagnostic testing procedure, PET Scans are expensive and attract extra scrutiny when billed. Modifier incompatibility created an excessive amount of denied claims where Modifier PI and/or PS (PET Scan modifiers specific to initial or restaging events) were used inconsistently.
  • High Denial Rates for Chest X-rays — Chest x-rays for pre-admission and pre-operative procedures were being rejected. Due to a lack of specific symptoms or diagnoses related to pulmonary or cardiac disease, these claims needed to define chest-specific involvement, i.e. heart, lungs, to be coded correctly. This was leading to a high rate of denials and lost revenue.
  • Surgery, including Abdominal Aortic Aneurysm (AAA) Repair or Surgery — Surgery charges were being denied due to incomplete documentation with a routine lack of specifics.
  • Co-Surgeon Reporting — Reimbursement was being delayed or denied on cosurgeon submissions due to a delay in uploading documentation.

Implementing Infinx’s Accurate Coding Services

Using eight full-time employees, Infinx initiated coding services utilizing a coding assistance and validation tool while offering the full breadth of coding, auditing, and education for the five specialty groups.

Infinx’s coding team utilizes the most accurate coding methods to ensure the coding is compliant with current medical coding policies and guidelines, and adherence to HIPAA standards. After an initial review, each claim is checked for documentation completeness. Then all appropriate CPT, ICD-10 CM, and HCPCS codes are selected while assigning and sequencing all codes for services rendered by the provider.

Internal Audit Process & Methodology

An ongoing audit process concentrates on performing daily in-depth audits to ensure coding integrity. All the errors are tracked as part of each coder’s performance. Every week, an Infinx auditor meets with coders to discuss the trend analysis and fill any knowledge gaps. Ongoing team training is also conducted based on audit findings.

Coding Refresher Assessment & Training

On a continual basis, root cause analysis informs the preventive action plan. Monthly In-House Coding Training:

  • Share healthcare & coding updates such as ICD-10-CM, CPT, and HCPCS changes
  • Cover healthcare industry topics relevant to coding
  • Discuss rejected diagnosis codes and further action
  • Gather and disperse information from the regional AAPC local chapter meeting

Client-Specific Coding Training:

  • Weekly or biweekly client updates
  • Support with new providers
  • Discussion on error category and error trend analysis report

Top-Level Coding Brought Successful Results

Throughout our engagement, Infinx has met or exceeded the client’s service-level agreement (SLA) metrics each month. As defined by the SLA:

  • 350 charges (diagnostic radiology), 60 charges (vascular & non-vascular / ENM / denials) per coder per day performed accurately and precisely
  • <1% reported errors per audit review
  • 24–48 hour turnaround time
  • Expert coding professionals and audits using advanced automation to review and correct codes with precision
  • Significantly reduced denials due to missing or incorrect information or codes

By offering top-level coding expertise, Infinx can improve revenue by reducing denials and days outstanding in accounts receivable. All Infinx coders are college graduates and have educational backgrounds that include life science and pharmacy programs. Each of the coders is certified with CPC, CIRCC, and CCS coding credentials.

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      1. Loria K. Putting the AI in Radiology. Radiology Today, Vol. 19, No. 1, P. 10.
        https://www.radiologytoday.net/archive/rt0118p10.shtml.
        Accessed on June 7, 2020.
      2. Carlson B. Molecular Diagnostics Market Now Larger than the Economies of 50 Nations, per New Report. Kalorama Information Website. October 30, 2019.
        https://kaloramainformation.com/molecular-diagnostics-market-now-larger-than-the-economies-of-50-nations-per-new-report/.
        Accessed on January 20, 2020.
      3. Atella V, Mortari A, et.al. Trends in are-related disease burden and healthcare utilization. Aging Cell, 2019 Feb; 19(1): e12681. Published online November 29, 2018. doi: 10.1111/acel.12861.
        Accessed June 1, 2020.
      4. Cohen R, Zammitti E. High-deductible Health Plan Enrollment Among Adults Aged 18-64 with Employment-based Insurance Coverage. Centres for Disease Control and Prevention NCHS Data Brief No. 317. August 2018. https://www.cdc.gov/nchs/products/databriefs/db317.htm.
        Accessed on January 24, 2020.
      5. PAMA Regulations, Important Update. CMS.gov, Centers for Medicare and Medicaid Services.
        https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/PAMA-Regulations
        Accessed on January 28, 2020.
      6. 2018 AMA Prior Authorization (PA) Physician Survey. American Medical Association, Prior Authorization Research & Reports. 2019. file:///C:/Users/katem/Downloads/priorauth-2018%20(1).pdf.
        Accessed on November 23, 2019.
      7. Yu Y, MD. Transforming the prior authorization process to improve patient care and the financial bottom line. MGMA, Knowledge Expansion Insight Article, Reimbrusement.
        https://www.mgma.com/resources/revenue-cycle/transforming-the-prior-authorization-process-to-im.
        Accessed June 10, 2020.
      8. Finnegan J. MGMA19: No progress to fix prior authorization, as practice leaders say it’s gotten worse. Fierce Healthcare. October 16, 2019. https://www.fiercehealthcare.com/practices/mgma19-no-progress-to-fix-prior-authorization-as-practice-leaders-say-it-s-gotten-worse.
        Accessed June 8, 2020.
      9. 2019 CAQH Conducting Electronic Business Transactions: Why Greater Harmonization Across the Industry is Needed, p. 2. 2020.
        https://www.caqh.org/sites/default/files/explorations/index/report/2019-caqh-index.pdf?token=SP6YxT4u.
        Accessed on January 30, 2020.
      10. Joint Authorship. Consensus Statement on Improving the Prior Authorization Process. American Medical Association. 2018. https://www.ama-assn.org/sites/ama-assn.org/files/corp/media-browser/public/arc-public/prior-authorization-consensus-statement.pdf.
        Accessed on January 22, 2020.
      11. Letter to the House of Representatives in support of Improving Seniors’ Timely Access to Care Act 2019 (H.R. 3107) from 370 Associations. September 9, 2019.
        https://www.rheumatology.org/Portals/0/Files/Coaliition-Letter-HR3107-Prior-Authorization-Reform.pdf.
        Accessed on January 30, 2020.
      12. Livingston S, Luthi S. House Committee Throws Spotlight on Prior Authorization Burden, Modern Healthcare. September 11, 2019. https://www.modernhealthcare.com/politics-policy/house-committee-throws-spotlight-prior-authorization-burden.
        Accessed on February 3, 2020.
      13. Ibid. 9.
      14. Industry Checkup: Measuring Progress in Improving Prior Authorization. American Medical Association. 2019.
        https://www.ama-assn.org/system/files/2019-03/prior-authsurvey.pdf.
        Accessed on February 2, 2020.
      15. Artificial Intelligence – What it is and Why it Matters. SAS Insights. 2020.
        https://www.sas.com/en_us/insights/analytics/what-is-artificial-intelligence.html.
        Accessed on February 1, 2020.
      16. Siwicki B. At RadNet, AI-fueled Prior Authorization Tech Shows Promise, Healthcare IT News, Global Edition. May 6, 2019. https://www.healthcareitnews.com/news/radnet-aifueled-prior-authorization-tech-99-accurate.
        Accessed on January 6, 2020.
      17. Napco’s iBridge Technology Named Top Innovation of 2014 by Security Sales & Integration Magazine – Recurring Revenue Model Makes iBridge a Top Choice for Security Dealers. January 13, 2015.
        http://investor.napcosecurity.com/2015-01-13-NAPCOs-iBridge-Technology-Named-Top-Innovation-of-2014-by-Security-Sales-Integration-Magazine.
        Accessed on February 3, 2020.
      18. Integrating Prior Authorization Solution with Epic PMS While Protecting PHI at a Pennsylvania Hospital Group. Infinx Case Study. 2018. https://www.infinx.com/resourcecasestudy/integrating-preauthorization-solution-with-epic-pms-lt/.
        Accessed on February 2, 2020.
      19.  Implemented a Complete Overhaul of Revenue Cycle Management Program for Large Hospital-Owned Cardiology Clinic. Infinx/Enhanced Revenue Solutions Case Study. 2018.
        https://www.infinx.com/resource-casestudy/implemented-a-complete-overhaul-of-revenue-cycle-management-program-for-large-hospital-owned-cardiology-clinic/.
        Accessed January 12, 2020.
      20. Ibid. 9.
      21. *******Chhaltralia V. What Does the Future Hold for Artificial Intelligence? Industry Analysis and Graphic, AI Business. March 22, 2018. https://aibusiness.com/industrygraphic-artificial-intelligence/.
        Accessed on February 2, 2020.
      22. Maximize Hospital Revenue with a Holistic Insurance Discovery Strategy. January 7, 2019.
        https://revcycleintelligence.com/news/maximize-hospital-revenue-with-a-holisticinsurance-discovery-strategy.
        Accessed on January 20, 2020.
      23. How Using Insurance Discovery Can Significantly Improve A/R, Infinx Blob. January 23, 2020.
        https://www.infinx.com/blog/how-using-insurance-discovery-can-significantlyimprove-a-r/.
        Accessed on January 23, 2020.
      24. 2018 Survey of America’s Physicians: Practice Patterns and Perspectives. The Physicians Foundation, Empowering Physicians/Improving Healthcare. 2019.
        https://physiciansfoundation.org/wp-content/uploads/2018/09/physicians-survey-results-final-2018.pdf.
        Accessed on January 30, 2020.
      25.  New Findings Confirm Predictions on Physician Shortage. Association for American Medical Colleges. April 23, 2019. https://www.aamc.org/news-insights/press-releases/new-findings-confirm-predictions-physician-shortage.
        Accessed on February 1, 2020.
      26. Reporting appropriate use criteria in claims for Medicare Patients. American Medical Association. August 17, 2020.
        https://www.ama-assn.org/practice-management/medicare/reporting-appropriate-use-criteria-claims-medicare-patients.
        Accessed on August 19, 2020.