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At home with coding: western healthcare system improves revenue cycle management via home coders.

A healthcare organization's revenue cycle is only as good as its coding. Too few coders results in a backlog of patient charts, which increases the number of unbilled accounts and accounts receivable (A/R) days. Poor coding means more claim denials and reworks.

Sometimes, an organization will settle for fewer coders or less experienced ones, but it doesn't have to--and it shouldn't.

Brainstorming Solutions

Sisters of Charity of Leavenworth Healthcare System (SCLHS) is an eight-hospital healthcare ministry with locations in California, Colorado, Kansas and Montana. It also owns four clinics, staffs a total of 2,066 beds, and employs more than 11,000 full-time equivalents, only a small percentage of which are experienced medical record coders.

In January 2000, SCLHS executives initiated an effort to increase the ministry's cash flow by improving the revenue cycle. Each hospital formed a revenue cycle steering committee consisting of its directors of scheduling/admissions, case management, health information management (HIM), business office, managed care and finance. All steering committees made assessments of the revenue cycle across the facilities.

We identified seven key, monthly revenue cycle measurements to monitor, three of which were impacted by coding: unbilled accounts, A/R days and claim denials--areas in which SCLHS was performing below industry standards. We attributed these results to two primary factors affecting all facilities--a shortage in coders and coding workload issues---and concluded that these were the greatest concerns. Next, we proposed six projects to address revenue cycle concerns, two of which related to coding.

We designated Saint John's Medical Center in Santa Monica, Calif., for the coder shortage project, because 40 percent of its $18 million in unbilled accounts were due to a backlog of outpatient charts that had not been forwarded to its medical records department. Also, the organization had four unfilled coder positions, representing about one-third of its coder staff. Saint John's HIM Director Debora Hadeen suggested that the project involve eWebCoding, an application service provider of Web-based remote coding solutions, to determine whether a work-at-home option would boost recruitment of experienced coders.

For the coding management project, we chose a study of Providence Medical Center in Kansas City, Kan., since it employed several coder trainees and produced a coding error rate that was higher than desired, although still better than the national average. We wanted to examine the accuracy of interventional coding for high-revenue and high-volume specialties such as cardiology and radiology.

Between 2000 and 2002, we presented all of our proposed projects to the CFOs council, which had to approve a charter for each project before it could begin. After reviewing our business case for the Saint John's project based on an eWebCoding ROI template, which demonstrated that the project would generate enough cash in the same fiscal year to match the upfront costs of implementing it, the CFOs approved the project. They also approved the Providence study based on a similar business case. Everyone agreed that the HIM steering committee should complete the Saint John's project before beginning the Providence study, since eWebCoding, although not involved in the latter project, might have a role to play following its completion.

Reaching Out to Coders

Saint John's Medical Center is a 450-bed multispecialty hospital in the competitive Los Angeles healthcare market. We had difficulty attracting experienced coders, mostly because we could not match the pay offered by other area hospitals, and coders were not inclined to drive to Saint John's on crowded freeways for limited wages. We were so short of coders that we often had to settle for trainees who required a lot of teaching and oversight to assure compliance and quality performance.

We thought a work-at-home capability would attract experienced coders throughout the West, but we lacked sufficient technology to accommodate coding at home. For example, no facility had the ability to transmit document images securely. We didn't have adequate firewalls in place to permit remote access to our network, and we couldn't implement a quality-assurance program to monitor such activities.

By utilizing eWebCoding in summer 2002, we committed to providing remote coders with the Internet-enabled equipment necessary for them to code at home. In return for giving full-time remote coders flexibility in working 40 hours per week, we insisted that, as a sign of their commitment, they create specific work-only areas in their homes that our supervisors could visit. We also required at home coders to dial in for monthly administrative meetings.

The response from Los Angeles area coders was overwhelming. Some coders actually said they would gladly take a little less pay if it meant not having to drive the Los Angeles freeways to work. Within three months, we hired three new coders. Since then we have retained a full complement of coding staff at Saint John's, with about 70 percent of the total working from home.

Within the project's first month, we reduced our unbilled accounts by 18 percent. We accomplished this in part by installing scanning stations at remote care locations to process charts more quickly and by automatically routing coding denials from the business office to the staff who worked on them. Supervisors monitored remote coding as it occurred, and they communicated in real time with coders via e-mail instant messaging.

Virtual Interventional Coding

In October 2000, we hired consultants to conduct a study of the interventional coding for cardiology and radiology cases at Providence Medical Center, a 400-bed, acute care community hospital. We were concerned about undercoding reimbursement issues as well as our interventional coders' knowledge.

We already knew that we lacked a sufficient number of experienced interventional coders. Because interventional coders have complex duties, they are difficult to find, and they must be compensated better than typical coders. Since we could not afford many experienced interventional coders, we outsourced some of these duties to contracted specialists. However, the responsibility of most interventional coding fell on our inexperienced coders.

The study offered three conclusions: We were losing reimbursement due to undercoding of charts; our interventional coding for cardiology and radiology cases was not consistent across facilities; and we could fix these problems if we assigned the correct codes during interventional coding.

Based on this, we decided to develop a virtual interventional coding support center (ICSC) for interventional coding of cardiology and radiology cases using eWebCoding. Since different facilities might have different interventional coders who are specialists in particular areas, we can make these coders available to all facilities via the ICSC, regardless of the coders' or the facilities' locations. Sharing resources means we don't have to employ the same kinds of interventional coding specialists at each facility, so we will reduce our overall need for interventional coders.

Embracing Remote Coding

Based on these projects, SCLHS negotiated a systemwide contract with eWebCoding in October 2002. In the last fiscal year, our ministry reduced its A/R days by three days to a record low of 51 days across the entire enterprise. We now have more experienced coders performing more efficiently for all facilities. Additionally, since facilities can share coders if necessary and we can easily attract experienced coders, we no longer experience the number or duration of coder vacancies that we once did. This helps to ensure that SCLHS receives the correct reimbursement for its services.

In the near future, we plan to establish a central virtual coding office to receive member hospitals' scanned and uncoded charts during times of coder vacancies or spiked coding volumes.

For more information about remote coding solutions from eWebCoding,

Mary Anne Pace is the director of revenue cycle services for Sisters of Charity of Leavenworth Healthcare System, Kansas City, Mo.
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Title Annotation:Remote coding/ASPs: case history
Author:Pace, Mary Anne
Publication:Health Management Technology
Date:Sep 1, 2003
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