Reinventing radiology reimbursement

Area of Science:

• Healthcare Administration
• Medical Coding
• Revenue Cycle Management

Background:

• Lee Memorial Health System (LMHS) faced an 84.5% medical coding error rate, leading to significant annual reimbursement losses.
• The existing system resulted in an estimated annual reimbursement loss of $182,000 due to coding inaccuracies.

Purpose of the Study:

• To address high medical coding error rates and associated financial losses.
• To implement and evaluate the effectiveness of a clinical reimbursement specialist (CRS) system in improving coding accuracy and revenue capture within LMHS.

Main Methods:

• Implemented a Clinical Reimbursement Specialist (CRS) system, starting with emergency department, cardiac catheterization, and radiology departments.
• The Radiology Reimbursement Specialist (RRS) role integrated expertise from radiology technology, medical coding, financial auditing, and billing.
• Instituted daily charge audits and active code reviews to identify and rectify coding errors.

Main Results:

• The RRS system increased radiology productivity by capturing over 3,000 RVUs and 1,000 additional units of service in its first year.
• Referrals for coding resolution from billers decreased from an average of 9 accounts per day to less than 1 per day within the first year.
• Resolution time for coding conflicts improved from an average of 4 business days to within 24 hours.

Conclusions:

• The CRS system, particularly the RRS role, effectively reduced coding errors and financial losses.
• This system enhanced operational efficiency, improved revenue capture, and positively impacted physician relations.
• The integration of specialized coding expertise is crucial for optimizing healthcare revenue cycles and ensuring accurate billing.