Coding software is a wise investment for medical practices that want to maximize revenues, maintain compliance, and support their billing staff.
By Andria Jacobs, RN, MS, CEN, CPHQ
Although airline pilots receive hundreds of hours of hands-on training and flight time, every aircraft is equipped with an operations manual, along with step-by-step checklists for every conceivable scenario. An airplane is a complex conglomeration of parts, and no one person can claim to know everything.
Likewise, billing and coding professionals should take the same approach to their jobs, relying on their experience but understanding they can never keep up with constantly changing codes and standards that vary by insurer.
Coding software is a wise investment for medical practices that want to maximize revenues, maintain compliance, and support their billing staff. Here are seven reasons you should invest in coding software.
1. Reduce the number of rejected claims.
The claims denial rate has held steady over the past few years, averaging between 5-10%, according to the American Association of Family Physicians.1 Consider the total revenue at your practice, then subtract 10%. Can your organization afford to lose that much money?
With coding software, users can check CPT® codes for accuracy before submittal with a particular payer, including Medicaid, Medicare, and a patient’s specific policy to reduce the chances of a claim getting rejected. Coders can focus their efforts on the unusual or more involved patient encounters, which are more likely to come under payer scrutiny.
2. Increase revenues.
Increasing the first pass claims rate by coding intelligently on the front end will result in higher revenues. But practices also can increase revenue by reworking and resubmitting claims. The cost to rework a claim has been pegged at $25, and up to two-thirds of rejected claims are never reworked. Even the most efficient practices are leaving substantial money on the table if they aren’t actively reworking claims.
Coding software can help here, too. By going back through the visit notes, a coder can research rejected codes and determine if a more appropriate code exists. Insist on software that presents rules rationale in simple terms that even novice coders can understand.
3. Create intelligent appeals.
Most reworked claims are relatively straightforward to correct and resubmit. The more complex the office visit or procedure, however, the more likely that claim will be rejected. Don’t despair—arm yourself with the latest coding information and edits from your coding software. By validating the medical necessity and the correctness of the claim, you’ll increase the chance that your appeal will be successful.
4. Receive frequent software updates.
Whatever coding resource or tool you’re using, how big is the code set and how often is it updated? Codes can change daily and often did, for example, early in the COVID-19 pandemic, when CMS created or updated codes related to the care of coronavirus patients and telehealth visits.
Some databases contain over 45 million codes that cover federal payers and most private insurance companies. The most robust databases are updated at least quarterly—and more often when substantial coding changes occur. When investigating coding solutions, be sure to ask about code set size and update frequency.
5. Support work-from-home arrangements.
The pandemic forced fundamental changes at the bedside as well as in the back office, as many coders retreated to home offices and have not returned. You need a coding solution that’s web-based to facilitate remote working arrangements while giving staff the critical tools they need to keep your practice running.
Web-based software can be accessed from any internet-enabled device. It also means that updates can occur more frequently, ensuring your coders have the latest edits.
6. Protect yourself and your practice.
CMS has been getting tough lately regarding claims. In September 2020, the U.S. Department of Justice announced its largest-ever healthcare fraud and opioid enforcement action in history, which resulted in charges against 345 defendants and alleged fraud losses topping $6 billion.2 The CMS Center for Program Integrity also announced the revocation of Medicare billing privileges for 256 medical professionals for alleged telemedicine fraud cases.
Private insurers also look for outliers, those practices or facilities that have the most claims or routinely bill for the most complex visits and procedures. By understanding and documenting the medical necessity of each claim, you keep your practice and yourself on the right side of the law.
7. Code with confidence.
Just like those highly skilled airline pilots who rely on electronic documentation to supplement their training and experience, coding professionals need the same sort of intelligent resource that coding software represents. No one can remember the right code in every situation, and a validated, online resource is an important part of coding right the first time, which reduces denials, increases revenue, and helps preserve the integrity of your practice.
 Andria Jacobs, RN, MS, CEN, CPHQ, is the chief operating officer for PCG Software and has more than 25 years’ experience in the healthcare industry, encompassing both administrative and clinical arenas. Prior to joining PCG, Jacobs was the administrative director of medical management for VertiHealth Administrators. Previously, she was an independent consultant in ambulatory care and practice management, where her clients have included hospitals, physician groups, and the University of California, Los Angeles.
Resources
1 https://www.aafp.org/dam/AAFP/documents/practice_ management/admin_staffing/FiveKeyMetricsPresentation.pdf
2 https://www.justice.gov/opa/pr/national-health-care-fraud-and-opioid-takedown-results-charges-against-345-defendants
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