hbRecon – hbCOR

Posted on June 10, 2024

The Case for hbRecon: Comparing Clinical Registry Data and Claims-Based Auditing Tools

Learn how integrating claims-based audits with clinical registry data-based audits like hbRecon provides more actionable insights to optimize financial and clinical performance.

Conducting coding audits is crucial for healthcare organizations in maintaining accurate billing, compliance with regulations, revenue integrity, and quality improvement. In turn, audits provide insight into optimizing coding practices, ensuring the delivery of the highest-quality care, and identifying missed opportunities for appropriate reimbursement. When performed more granularly, audits allow for optimizing the coding processes, accurately capturing all eligible services and procedures while minimizing financial and legal risks.

Historically, claims-based audits have been the standard practice; however, registry data-based audits provide an alternative, nuanced insight into each episode of care and associated event. While claims-based solutions utilize billing data to investigate the revenue cycle journey, hbRecon uses clinical registry data, which provides unique insights into uncovering coding errors that lead to missed revenue opportunities.

The Difference Between Clinical Registry Data and Claims Data

So, how do clinical registry data and claims data differ? Clinical registry data and claims data are valuable information sources in the healthcare industry, but they serve different purposes and have distinct characteristics.

Clinical registry data from sources such as the American College of Cardiology (ACC), the Society of Thoracic Surgeons (STS), Extracorporeal Life Support Organization (ELSO), the American Heart Association (AHA), and State Organizations (COAP & CCORP), includes discrete data elements that contain detailed clinical information about patients, diagnoses, procedures, and outcomes. It is particularly useful in auditing the clinical processes and outcomes of specific medical procedures or conditions.

On the other hand, claims data refers to information collected from insurance claims submitted by healthcare providers for reimbursement purposes. This coded data source includes details about the services provided, such as procedures performed, diagnoses, medications prescribed, and associated costs. However, information for each claim is limited, and it doesn’t capture all aspects of a person’s treatment or health – many things must be inferred.¹

Expanding Your Toolkit for Effective Auditing

Both clinical registry data and claims data are instrumental in medical data auditing. Claims data is typically used for financial audits and to assess the appropriateness and accuracy of billing and reimbursement practices, aiming to ensure coding accuracy, compliance with payer requirements and regulatory standards, and integrity of the submitted claims data. On the other hand, clinical registry data provides deeper clinical insight to determine if the claims’ codes appropriately represent the services provided and diagnoses assigned, revealing any missed opportunities for revenue capture due to miscoding. This increased specificity allows auditors to assess adherence to clinical guidelines, identify variations in care, and evaluate patient outcomes.

When segregated, the audits’ data sets lose efficacy. For example, a claims-based audit may determine the claim’s coding to be accurate, but this audit alone cannot determine if additional, necessary coding was omitted due to insufficient provider documentation or missteps in translating clinical language into coding language, especially around MCC and CC conditions. However, clinical registry data-based audits, analogous to the hbRecon-based audit, can reveal potentially missed diagnoses and/or treatment codes, reducing the risk of undercoding or missing revenue opportunities.

The integration of both audit types provides a more comprehensive and accurate assessment of healthcare quality, outcomes, and financial performance. With this synergistic approach to healthcare delivery, it’s possible to ensure that both clinical and financial aspects are aligned and optimized. This is where hbRecon’s use of clinical registry data in conjunction with claims data in the audit process demonstrates its distinctive superiority when uncovering errors in revenue capture.

Harness the Power of Clinical Registry Data With hbRecon

When it comes to revenue capture, the following factors demonstrate why clinical registry data offers superior results:

Clinical Specificity and Coding Accuracy. hbRecon analyzes clinical registry data with detailed discrete & structured clinical information about a patient encounter, including diagnoses, procedures, treatments, and outcomes. This level of specificity allows for an accurate and comprehensive comparison of the services provided and the services billed, leading to improved revenue capture.
Comprehensive Data. Clinical registry data often includes information beyond what is captured in claims data. It may include additional clinical measures, patient-reported outcomes, and quality indicators that provide a more comprehensive view of the patient’s condition and treatment. One clinical registry module alone can warehouse over 2,000 data elements in a single visit. With the hbRecon toolkit, this additional information can support accurate documentation and coding, leading to improved revenue capture.
Quality Improvement. Clinical registry data is often used for quality improvement initiatives, clinical research, and benchmarking. These activities focus on optimizing patient outcomes and care processes, which can indirectly impact revenue capture by enhancing the quality and efficiency of care delivery. hbRecon allows users to review all relevant clinical registry, financial, and coding data in one location.
Patient Acuity. This is where hbRecon’s use of clinical registry data shines again, capturing a better picture of the patient’s acuity – because if the coding is wrong, patients may appear healthier or sicker – lending to a more accurate CMI. From there, hbRecon translates that into the associated diagnosis-related group (DRG) code, adding a CC or MCC when applicable. This benefits the cardiovascular population by better reflecting their actual patient acuity, CMI, and severity of illness, which makes way for appropriate quality improvement initiatives and medically indicated clinical research, ultimately enhancing patient outcomes and care processes.
Beth Kennalley, a quality professional with one of hbRecon’s major hospital clients, shared what she found most valuable about implementing hbRecon in terms of efficient and accurate billing: “The ability to be able to compare two independent chart abstractions is invaluable but would take too much time to do manually to be useful. This tool allows us to do this, find multiple errors quickly, and promptly submit this information for correction. The tool has reassured us that our billing is accurate in these areas.”

Beth shared that hbRecon’s monthly review of abstraction and coding differences has taken less and less time, and her organization has improved performance in both areas. Efficiency is critical to her ability to quickly and accurately review both data sets to ensure they accurately reflect the case performed.

hbRecon: Translating Clinical Data for Coding Specificity

hbRecon’s phased approach for clinical registry data auditing is a valuable tool for increasing revenue capture with its unique clinical registry and coding data dataset, providing detailed and specific clinical information about patient encounters, allowing for accurate and complete coding based on the documentation of services provided.

Is your healthcare organization ready to discover alternate revenue streams through the hbRecon toolkit? Our platform can integrate clinical registry and coding data sources to algorithmically analyze and determine recommended billing codes and identify probable coding mismatches and rebilling opportunities.

Schedule a discovery call today: https://www.heartbase.net/social-discovery-call

Sources

MIT OpenCourseWare (Dec 13, 2018) 4.3.3 Healthcare Costs – Video 2: Claims Data https://www.youtube.com/watch?v=WYrDTn37m-I

Posted on May 8, 2024

Navigating Medicare Coding Changes to Maximize IVL Revenue Capture

Learn how hbRecon helped one IDN recover hundreds of thousands of dollars in missed revenue for IVL procedures by performing a coordinated data audit.

Intravascular lithotripsy (IVL) is a novel procedure used to aid in the treatment of severely calcified coronary artery disease. As IVL procedures have grown in utilization since FDA approval in 2021, hospital coding departments often struggle to document the correct utilization for each patient, especially as Medicare continues to shift its coding guidelines to ensure proper reimbursement.¹ Utilizing heartbase’s hbRecon Toolkit, one integrated delivery network (IDN) seamlessly navigated the recent Medicare IVL coding changes, identifying over $300,000 in services that would have otherwise gone unbilled.

Implementing new coding guidelines is a critical challenge for cardiac services billing departments. Whether a coder is unaware of the specific changes or fails to recognize how these changes apply, the end result is a missed code and limited reimbursement. A 2023 report from Shockwave Medical, the pioneer in IVL technology for coronary procedures, describes the most recent Medicare coding guideline changes for IVL:¹

Turning Missed IVL Codes Into Six-Figure Revenue

“Starting October 1, 2023, three new Coronary IVL-specific Medicare Severity Diagnosis Related Group (MS-DRG) codes have been established for Percutaneous Coronary Intervention (PCI) procedures involving Coronary IVL in the hospital inpatient setting. The New Technology Add-on Payment (NTAP) for Coronary IVL will conclude on September 30, 2023.
Additionally, the final 2024 Medicare Inpatient Prospective Payment System (IPPS) rule consolidates the prior four MS-DRGs involving PCI with implant of a stent into two MS-DRGs, removing a previous distinction between stent type – Drug Eluting Stent (DES) or Bare Metal Stent (BMS). PCI with stent procedures utilizing alternative plaque modification therapies such as atherectomy, cutting or scoring balloons without the adjunctive use of IVL will map to PCI MS-DRGs 321-322.”
Shockwave Medical. (2021, February 16). Shockwave Intravascular Lithotripsy FDA Approved to Treat Advanced Heart Disease [Press release]. https://shockwavemedical.com/about/press-releases/shockwave-intravascular-lithotripsy-fda-approved-to-treat-advanced-heart-disease/

Despite significant changes to reimbursement structures, countless coding departments continue to operate on previous guidelines. As a result, this IDN missed IVL reimbursements from over two dozen procedures by failing to use the new ICD10-PCS codes. Leveraging the hbRecon toolkit, the IDN performed a coordinated audit to locate these discrepancies and identify where the IVL was miscoded in each claim. From October 2023 to February 2024, hbRecon identified 27 cases across nine sites with missed IVL codes, recovering hundreds of thousands of dollars in unbilled revenue.

Maximize Accurate CV Services Revenue With hbRecon

The struggle to properly capture and code IVL charges is just one example of the widespread challenge facing cardiac service coding teams in nearly every major hospital and health system across the country. To help close the gaps in coding and documentation coverage, hbRecon uses advanced software-driven tools to algorithmically analyze coding, clinical registry, and financial data, identifying mismatches and recommending proper Diagnosis Related Group (DRG) codes. hbRecon helps billing teams determine how to correct their coding and registry data, optimizing their processes to accurately reflect each episode of care and, ultimately, build a more profitable cardiac services department.

Reach out to learn more about how hbRecon can help your facility eliminate coding gaps and maximize reimbursements for cardiac services.

Sources

Shockwave Medical. (2021, February 16). Shockwave Intravascular Lithotripsy FDA Approved to Treat Advanced Heart Disease [Press release]. https://shockwavemedical.com/about/press-releases/shockwave-intravascular-lithotripsy-fda-approved-to-treat-advanced-heart-disease/
Coronary Intravascular Lithotripsy (IVL) & Percutaneous Coronary Intervention (PCI): 2024 Medicare Hospital Inpatient Reimbursement Coding and Payment Guide. (2023). Shockwave Medical. https://discover.shockwavemedical.com/hubfs/shockwave-medical/Coronary%20IVL%20Hospital%20Inpatient%20Coding%20Guide.pdf

Posted on June 30, 2023

Heartbase, Inc. Certified in ACC-NCDR Chest Pain – MI v3.1

CHICAGO, IL – As of June 30th, 2023, we are excited to announce that heartbase™ is officially certified by the ACC-NCDR for Version 3.1 of the Chest Pain – MI Registry Database. Heartbase users, please visit the heartbase hbKnowledgebase to view the recording of Carmen Ernst’s walkthrough of this new version – please click here. The heartbase staff highly recommends that users view the recording, as this version change was substantial in scope.

From the ACC-NCDR website:

“For more than a decade, the Chest Pain – MI Registry™ has been the single, most trusted source for outcomes-based, continuous quality improvement and remains the go-to registry for hospitals and health systems applying American College of Cardiology (ACC) and American Heart Association (AHA) clinical guideline recommendations.”

Participation offers:

Integration & Interoperability with other heartbase hbCOR registry events.
Interoperability options from other hospital systems, such as Epic Clarity, to allow for the pre-population of discrete fields.
A comprehensively streamlined & customizable electronic DCF, improving upon the flow and functionality of the ACC Online Tool, with options such as role-based access.
Simplified reporting with the hbQuery Tool, with measure reporting and other standard reports to follow.
Integration with the hbRecon Module to ensure CP-MI cases are correctly coded and billed, maximizing reimbursement.
Planned hbAnalytics updates to include new measure reporting and associated breakout reports.

If you’re a CP-MI data manager or abstractor and would like to take a look at our new forms, please contact heartbase Client Account Manager Alex Potanos to schedule a review session.

About heartbase, Inc.

Heartbase™ is a privately-held company founded in 1992 and designed to be intuitive & centered on the needs of the clinician. Since our inception, we have known that the most effective way to develop a robust and reflexive software platform is through collegial partnerships with our clinical & financial users. Working directly with our customers – listening to their concerns and honoring their suggestions for improvement – allows us to build a tool that is fast, efficient, and tailored specifically to the individual needs of each healthcare institution.