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Computer-Generated Infusion Coding Explained

Recently, MedAptus has introduced a new and innovative product – Charge Capture INFUSION – which automatically converts start/stop times for infusion events into the correct codes and then automatically sends the code to billing. This means that because of computer-generated infusion coding, nurses no longer have to worry about compliance or accuracy, while other coders can now be re-directed to other areas.

Charge Capture INFUSION builds on MedAptus’s long experience in developing charge capture software. One of the primary architects of the software’s development has been Gary Bernklow, product director. Gary shared with us some of the interesting aspects of this product and where he thinks it’s going.

To start with, Gary, how long have you been with MedAptus and what has been your role or roles?

I have been with MedAptus now for 10 years. I was originally brought onboard as the product director for our Facility Charge Capture product, which also includes our Infusion module. Of course, I have served in a variety of other roles within the company as well, including project manager and implementation manager. I was hired primarily as a subject matter expert for Professional and Facility billing and coding. Prior to my service with MedAptus, I had nearly 20 years of experience in Revenue Cycle management at a large private practice and at the Massachusetts General Hospital and I have extensive experience with both professional billing and coding and facility billing and coding.

What changes have you seen in charge capture over the years and specifically infusion?

The biggest trend I have seen is that there has been a continuous movement away from inpatient hospital services. Many key inpatient revenue centers now offer many of the services in outpatient clinics. Payers and CMS realize that ambulatory care is cheaper and they are incenting payments accordingly. That means hospitals must now compete with physician freestanding clinics for the same patient services and there are ever-shrinking margins for much of the DRG/Inpatient services.

Outpatient infusion centers have been coping with very small margins ever since the current OP Infusion billing rules went into effect around 2006. The rules changed every year, adding and removing codes, defining time limits, creating the specific hierarchy—first as a recommendation then as an immutable rule—and defining the primary or “initial” service. At most infusion centers, Nurses were responsible for recording the infusion charge and the highly complex rules meant intensive training and re-training every year for them to be able to record and accurately charge. They had to become coders in addition to their nursing duties. More paperwork, less patient work.

Infusion centers adapted to the new rules in a variety of ways, but the two most popular were to either continue to let nurses record their infusion start and stop times in documentation and then try to figure out the time-based codes and record those themselves, or the organization chose to address the problem by assigning a bunch of trained coders to review the documentation and convert the times to codes. Neither is an ideal solution. Nurses will not be as accurate as coders, and while hiring large numbers of coders to review infusion times and documentation may produce accurate codes, it is also a huge expenditure of resources that could better be used in other areas. Since the billing codes are determined by the time and duration of the infusion service, miscalculating that duration by even one minute could result in missed charges worth hundreds of dollars. And forcing nurses to record start and stop times twice (once for documentation and once for billing) increases the possibility of manual errors to be present.

In most EHR’s the drug, start, and stop time is already documented. That is really all the information required to produce accurate coding. If we could grab that information directly from the EHR, we could apply the time and hierarchy rules and produce the billing codes automatically.

Tell us how computer-generated infusion coding and specifically Charge Capture INFUSION works?

We are introducing fully automatic coding based on the documentation of the infusion service found in the EHR. Our product looks at the documentation for the service, finds the drug, the infusion start time, the infusion stop time, and calculates the exact billing codes required for that specific service. When an infusion is performed and documented in the chart, we can pull that documentation, produce an accurate billing charge, and send that directly to the client’s billing system (or back in the EHR) with no other intervention required. The resulting charge codes will match the documentation exactly and be 100% compliant. There would be no lost charges due to “estimating” the duration of the infusion, and no need for coders to review every encounter for billing accuracy. What is in the chart reflects what is in the charge.

Since the start and stop times are recorded once, and the billing codes derived from those values, there is zero chance for manual errors in the codes. If a value is incorrect in the documentation, it can be corrected there and the new values corrected in our system as well, automatically.

Basically, we do all the math to calculate the type of infusion (Chemo, Med, Hydration; Long infusion or Push), the duration of that infusion, and the number of billable units resulting from that duration. With complex coding like we have for hydration, we believe it is much more efficient and accurate to let the technology do the hard work.

We accomplish this with several interfaces, one from the EHR into MedAptus providing drug identifiers and start/stop times for those drugs, and another from MedAptus into our clients billing system or into the EHR with accurate codes.

What makes this product so different than what’s currently out there in the marketplace?

The biggest differentiator with our system is the automatic code creation. There are several products that allow users to manually plug in their drug types and start/stop times, and have the billing codes created from that information. We even have that option available in MedAptus as well.

However, this requires that information to be entered twice—once in the EHR and again in the charge capture software. Users have to record the drug, the start, and the stop time in the EHR and then record the drug, the start, and the stop time in our manual infusion system.  If the information already exists in the EHR, why can’t we just pull that information into our MedAptus Infusion system and calculate the correct codes without having to have someone enter the same information again?

I don’t believe there is any other Infusion product that does that, but it seems to be the most efficient way to generate an accurate charge.

What are the biggest misconceptions people have about Charge Capture INFUSION?

The biggest misconception I have heard is that this is an incredibly complex solution that will take  months and months to implement. While there is some integration work that will need to be done, we don’t have to create the logic to convert time to billing codes. We already have that in place and have had it since 2007.  We have a tremendous Integration team that has developed interfaces with the major EHR systems including Epic, Cerner, Allscripts, McKesson, and we have developed integration specs to help our clients address their questions. Training is minimal due to the product being mostly automatic.

Implementation can be very quick. The process is not the same as implementing an EHR for example. I often hear potential clients worried that the process will be long and painful. That is not the case.

Another misconception that I see often is that clients believe their EHR already has the necessary tools in place to create accurate infusion coding. It’s true that most EHRs now provide some kind of mechanism for charge capture, but none of them can translate infusion duration into billing codes. So if your EHR representative says they can provide that service, please ask for a demonstration.

Lastly, I hear from a great many organizations that their Infusion department is too small to take advantage of our system. In those cases, I typically ask them about their Emergency Department and the volume in that area. There are statistics that show 35% of all ED patients receive some kind of intravenous infusion service during their treatment. Those services must follow the same guidelines and hierarchy for outpatient infusion billing. Our solution would also be a good fit for those departments as well.

Tell us about some success stories you’re familiar with in terms of hospitals changing the way they capture infusion events for coding, especially in terms of computer-generated infusion coding.

As I have noted, Infusion coding is incredibly complex. I have often provided an evaluation of Infusion billing for our perspective clients, using our tool to analyze a subset of their infusion services for coding and billing accuracy. I have examined hundreds of infusion services and have found very high error rates with all records examined. I have seen error rates as high as 90%, and have yet to find any services with an error rate lower than 40%.

In the case above with the 90% error rate, Nurses were recording the charge codes on paper but had been trained for years to always round the infusion time down to the nearest 15 minutes. This resulted in thousands of dollars of lost revenue. In the first 8 months of using our solution, their revenue jumped by nearly $4 million. The nurses were doing nothing wrong, but they had been trained incorrectly for years. Our product paid for itself within weeks. Miscalculating the infusion duration by even 1 minute can have disastrous effects on the bottom line.

This was an extreme case, but certainly not an unusual one. By “rounding” the duration of infusions downward, this client was effectively removing valid billing units from their charges. Other common errors include not charging for Hydration when it was delivered, incorrectly charging multiple units for concurrent infusions, and choosing the wrong infusion as the “initial” service.

Is there anything else you’d like to add or mention?

We have been managing Infusion coding for more than 10 years now, and during that time the single request we have had from our clients and perspective clients has been that we figure out a way to provide this product without requiring our clients to have to “repeat” their infusion times. Nurses and coder both told us, “Don’t make me enter the same information twice”. We listened to our clients and have provided a solution that makes their documentation easier, provides a proven return on investment, and assures 100% compliance between billing records and patient documentation.

I am very proud of this product and I do believe it can make a positive impact to any organization delivering outpatient intravenous infusion services.

To learn more about Charge Capture INFUSION, click here.