With the pandemic subsiding in some areas, healthcare providers that had locked down their facilities are now opening up with appropriate controls in place based on guidelines from CMS. Social distancing had put non-COVID-19 services on hold, and postponed or canceled procedures has caused a dramatic decrease in revenue in health care facilities. New codes and rules have been introduced, including for telehealth, and the reimbursement landscape is uncertain. In addition to treating COVID-19 patients, there is now greater focus on outpatient services in preparation for greater demand for non-emergent non-COVID-19 healthcare. Providers need to implement best practices to ensure accurate claim submission and maintain revenue cycle business continuity. Outsourcing medical billing to an expert is a practical option to navigate these challenging times.

Here are six best practices for achieving compliance and revenue integrity in the current environment:

  • Coding and billing compliance: Providers need to follow and adhere to the latest coding and billing guidance from the CDC, CMS, AMA, and other official organizations. New ICD-10, CPT and HCPCS codes and guidelines were introduced for COVID-19 tracking and billing. The new telehealth policy that became effective from March 17, 2020, enables physicians to receive reimbursement for providing telehealth services to Medicare patients across the country, with fewer restrictions. There are specific codes for different types of telehealth consults, and new guidelines for billing telehealth visits and modifier use. Medicare and commercial payers have explicit requirements and rules for billing virtual visits. Now, with the resumption of elective and non-emergent procedures, providers also need to focus on error-free reporting of these visits.

    Prioritizing correct coding and billing is paramount to win the battle against claims denial. Staying up-to-date in payer rules is critical to reduce billing turnaround and reimbursement delays. Timely and continuous auditing of claims can reduce risk of errors that can lead to denials and rework. Monitoring delayed or denied claims promptly and implementing corrective action is also important to revenue optimization.
  • Complete, precise, accurate documentation: Assuring consistency and accuracy in provider documentation is a challenge for many organizations. Physicians need to understand the importance of accurate, specific, and unambiguous documentation for correct coding. An article in Revenue Cycle Advisor explains that using terms such as “probable,” “possible,” or “likely” to qualify diagnosis should be avoided. For instance, the article cites an expert as saying that if a patient’s discharge summary states “possible COVID-19 infection,” it won’t be coded as U07.1, and will instead reported using Z20.828 (contact with and [suspected] exposure to other viral communicable diseases) or Z03.818 (encounter for observation for suspected exposure to other biological agents ruled out).

    Precise documentation is necessary not only for COVID-19 coding and billing, but for services provided via telemedicine as well in-person visits. Physicians can ask their billing/medical coding service provider to determine what specific documentation the payer requires so they can provide that information. A clinical documentation improvement (CDI) programs ensure accurate translation of clinical work into the precise codes that best describe the severity of illness of patients and the complexity of care provided. Investing additional resources in CDI training and development will produce future returns for healthcare organizations. A Becker’s Hospital Review article recommends that providers broaden the scope of their CDI program with technology that uses clinical intelligence to drive concurrent documentation review for all payers.
  • A proper patient access strategy: This is crucial to maintain business continuity. While telehealth is an important strategy to improve patient access, managing patient access would also include measures to support a surge in uninsured patients and managing the potential demand for rescheduling elective care, according to Kelley Blair, senior vice president and general manager, Health Systems, Technology Enabled Services, Change Healthcare (Becker’s Hospital Review).
  • Task force to ensure regulatory compliance: A recent RAC Monitor report noted that monitoring of billing and claims data has already begun to ensure that hospitals are not upcoding to take advantage of higher COVID-19 reimbursement rates. accuracy of claim submission can be a challenge with new rules and codes. Setting up a task force for regulatory compliance can minimize potential revenue and billing compliance risks and optimize reimbursement in this evolving scenario.
  • Data analytics to improve cash collections: Providers need to leverage data analytics effectively to improve cash flow as patient volume fluctuations continue. In addition to utilizing the capabilities of their EMR system, they can benefit through expert third party support to improve revenue cycle performance. Providers of outsourced medical billing services utilize a combination of analytics and technology to monitor their clients’ RCM operations, tackle deficiencies, and make timely adjustments to cut billing turnaround and reimbursement delays.

With many changes to deal with, from new telehealth rules, modifiers, procedure codes for testing, and regulatory and reimbursement changes, healthcare organizations face significant challenges when it comes to revenue cycle management amid the pandemic. As they reopen, they must develop a comprehensive, proactive approach to manage patient volumes, optimize reimbursement, and remain flexible to manage complexities in an efficient way.