Cardiovascular (CV) physicians have a lot on their plates, but what they accidentally let slip through the cracks could be costing your CV program five- to six-figure revenue.
Clear, complete physician procedure/operative notes (Notes) that fully detail the services rendered for a cardiovascular procedure are the key to accurate reimbursement. Sometimes those Notes fall to the wayside during a particularly busy day. At other times, the physician simply isn’t aware that cataloging their experience has a direct correlation to the amount billed for the procedure.
Whatever the reason, hbRecon helps keep those critical details in focus for complete and accurate billing. Let’s follow along to see where a physician’s experience can get lost in the mix, from the procedure all the way through to coding and reimbursement.
The CV Procedure
A patient visits the hospital for a planned elective inpatient electrophysiology procedure – an Automatic Implantable Cardioverter-Defibrillator (AICD). During the procedure, the electrophysiologist implants the AICD, which functions as both a defibrillator and a pacemaker.
The procedure is a success, and the patient is discharged with no complications.
Unclear Procedure Note: The First Misstep
In the middle of their particularly busy day, the electrophysiologist hastily dictates their Notes on the procedure. Along with a brief overview of the services rendered, the electrophysiologist notes that the patient received a “pacer” or a “defibrillator pacer.”
The electrophysiologist submits their procedure note to the EHR and gets back to their busy day. Unfortunately, the lack of specificity in Notes means that accurate billing for the procedure has already gone off the rails.
Coding: Another Layer of Abstraction
Put simply, the coder’s job is to interpret the data they receive from the clinical team and assign a proper code that is used to bill the procedure. What physicians might not know is just how much room for interpretation their Notes can leave for coders.
Without explicit, crystal-clear Notes about every aspect of the procedure, coders are left to make reasonable assumptions about the services rendered, the intention behind those services, and other critical details that directly affect reimbursement.
In the case we’ve described here, there is one glaring point of ambiguity: the noted “pacer” or “defibrillator pacer.” While there is certainly room for CDI or Coding to issue a query to the provider in this instance, this is not always done.
There are several factors that contribute to an accurate code for pacers, including whether the device was newly introduced or a replacement, as well as the presence of complications or comorbidities.
Since those details weren’t clarified by the “pacer” or “defibrillator pacer” note, the coder in the case we’ve described reviews the clinical data available to them and settles on MS-DRG Code 262: Cardiac Pacer Revision Except Device Replacement without CC/MCC.
It’s a reasonable abstraction to make, but it unfortunately doesn’t represent that the device was actually an AICD.
Billing: The Financial Implications
Compared to coding, the biller’s job here is more straightforward. Billing considers the code recommended by coding and seeks reimbursement based on that code.
Unfortunately, the code that categorizes the device as a simple “pacer” rather than an AICD leaves a significant amount of money on the table — $15,000–25,000 per miscoded device, in fact. That money really adds up, like it did for Karen G. McNickle, RN, MSN:
“A few years back, we noticed that we weren’t getting our defibrillator cases coded correctly. We had 15 cases in one month that ended up being coded incorrectly. That got some real attention once we realized the lack of clarity in the physician’s notes.”
With that revenue, the hospital’s CV program could have saved toward new equipment or hiring a new staff member. However, due to the lack of clear communication between electrophysiologists and coders, that revenue is left on the table. That’s where hbRecon comes into play.
hbRecon: More Complete Clinical Data, More Accurate Billing
hbRecon helps clinicians and coders see eye-to-eye and provide an accurate, more detailed account of the services rendered. It integrates seamlessly into your existing heartbase workflows to present all the information about a CV procedure (clinical, coding, and financial) in one place, ensuring nothing slips through the cracks.
With hbRecon, clinicians can easily see how the Notes they provide have a direct impact on their CV program’s bottom line. It automatically identifies areas where greater specificity is needed, empowering clinicians to obtain the necessary clarification to assign the most appropriate DRG code and maximize reimbursement.
“We can’t take care of patients if we aren’t reimbursed appropriately,” says Karen G. McNickle, RN, MSN. “hbRecon gives us tangible evidence of the revenue we’re losing or could be capturing.”
The cost of ambiguous Notes is a tough pill to swallow, but hbRecon puts CV programs on a clearer, more profitable path. Schedule a brief demo of hbRecon to see how it can transform your own program’s bottom line.