The Healthcare sector is passing through turbulent times due to the COVID-19 pandemic, understaffing, bad insurance denial policies, government headwinds, as well as documentation and coding guideline shifts. Physician practices are working close to the edge and staying extremely focused on their revenue cycle performance to financially survive the pandemic and all the other factors driving down payments. The coding and billing industry too is seeing its share of challenges. The industry is confronted with the test of acclimating to the swift changes in payer rules and policies brought about by the pandemic. At the same time, the CDI and RCM sector is also going through digital transformation with innovations such as RevCDI-led coding leveraging Artificial Intelligence (AI) to optimize every aspect of the workflow and deliver improved compliance, while finding additional revenue enhancement opportunities.
Evolving Payer Rules
Centers for Medicare & Medicaid Services (CMS) has bolstered Quality Payment Program (QPP) and Merit-Based Incentive Payment System (MIPS) in its Physician Fee Schedule (PFS) 2022. As the shift in reimbursement methodology from fee-for-service to value-based care gains momentum, providers must maintain high quality of care while they choose to maximize compliant revenue. Although value-based programs offer incentives, they also impose penalties based on cost and quality performance. Physicians must ensure compliance or risk audits and denials. While the refinements made to the E&M rules benefit some specialties, others are left staring at a pay cut. The reduction of PFS conversion factor to $34.6062 for CY2022, a reduction of 0.82% from CY2021, has further burdened the already strained healthcare revenue cycle.
Since the beginning of 2020, in addition to the annual changes to ICD-10 codes, physician practices as well as coding and billing companies have dealt with the challenges of accurately documenting and coding for the novel coronavirus. The new CPT and HCPCS coding sets, assigned to report the procedures for screening and treating COVID-19 as well as vaccines, are constantly evolving. While this is expected to continue through 2022, PFS has introduced an additional 159 new codes, invalidated 30 codes, and revised 22 codes for the FY2022. Coders are now expected to familiarize themselves with these changes to support physicians.
With COVID-19 accelerating adoption of telehealth, innumerable outpatient visits have transitioned into virtual care, with 2021 seeing a 38-fold increase in telehealth visits compared to the pre-pandemic era. In 2022, significant shortage of physicians and staff, aging population, and increase in chronic diseases have further expedited this transition of care to virtual settings. Rules to report telehealth services are constantly changing with both Medicare and commercial insurance payers following specific guidelines. Coding and billing staff are now required to continuously learn as well as keep track of the frequent uncoordinated changes in telehealth payment policies.
With up to 40% of charges related to COVID-19 care denied in 2021, it is a significant challenge to code and report services related to COVID-19. The primary reasons for professional fee denials are "missing or suboptimal documentation", "duplicate claims", "failing to obtain prior authorization", "bundling denial", "non-covered charges", and "submission and/or billing errors." For hospital billing, the top reasons for denials are "secondary diagnosis / condition code / ICD procedure documented, but not billed" and "addition information needed". Mitigating these challenges will require physicians to improve documentation practices and work closely with coding and billing teams. This is not only essential to improve revenue, but also necessary to reduce compliance risks.
As physician practices continue to use information that is getting increasingly complex, it is crucial to capture and maintain data accurately. Digital transformation is rapidly changing the healthcare RCM sector, particularly in the CDI-led coding space. A robust digital-age CDI program together with a highly trained CDI team can empower physicians to capture comprehensive data that improves both compliance and appropriate revenue. Advanced AI platforms such as Natural Language Processing (NLP) and Machine Learning (ML) are assuming a bigger role in the CDI-led coding space, allowing for more precise medical transaction reporting. RevCDI, the proprietary clinical cognitive engine from Reventics, uses its advanced capabilities to detect deficiencies in medical charts and provide physicians with near real-time chart specific feedback, enabling them to make swift documentation changes for compliant coding and reporting. RevCDI also offers physicians customized education materials and comparative dashboards on deficiency levels non-intrusively in a meaningful way. All of this leads to improved first pass payment and more wins on appeal when claims are denied.