Coding Audits in Cardiovascular Care: Why Claims Data Isn’t Enough


Accurate revenue capture is crucial to protecting your bottom line, improving financial performance, and reducing the risks of audits and penalties. Most importantly, it informs strategic decision-making around pricing, investments, and resource allocation that drives future profitability of cardiology services and revenue cycle optimization. While claims data has traditionally been the method of choice for coding audits, relying solely on claims data for comprehensive coding audits brings several limitations. 

Limitations of Claims Data in Healthcare Audits 
Claims data comes from the information healthcare providers submit to insurance companies for reimbursement. Each data source includes details about procedures performed, diagnoses, medical prescriptions, and associated costs. 

However, there are limitations to relying solely on claims data for revenue capture, primarily rooted in the following coding quality issues that many cardiovascular providers face today1

  • Difficulties Keeping Pace with Changing Payer Requirements: Health insurers continually update and change coding requirements. For example, a new guideline for implanting a pacemaker may suddenly become available, and if the coding team isn’t up-to-date on the latest requirements, the claim could be denied.
  • Challenges Managing Coding Complexity: The range of CPT codes for cardiovascular procedures ranges from minimally invasive to complex surgical, and The American Medical Association changes CPT codes every year.1 It’s important to consistently revisit codes to ensure accurate coding and limit denials. 
  • Unclear Communication with Providers: Illegible handwriting or hard-to-decipher notes in EMRs make it difficult for coders.1 Coding can be further muddied by inputs from multiple providers, as well as physician notes lacking in clinical detail.
  • Poor Provider Coding Education: Providers may not fully understand the importance of accurate coding to the organization’s financial bottom line, making it crucial to educate providers on the necessity of using accurate codes and communicating with coders.1
  • Privacy: Patient privacy protections may limit the amount of information that can be included in claims data and – as a result – difficult to rely on claims data for revenue insights. 
  • High Turnover for Medical Coders: In 2023, coders took the lead as the most difficult group to hire in the billing office.2 Managing high staff turnover and the associated learning curves only exacerbate coders’ already challenging jobs of tracking changing payer requirements, coding complexity, and learning provider communication styles.

Revenue and Compliance Issues as a Result of Coding Gaps

Coding gaps can produce several revenue and compliance issues, including: 

Overbilling: Overbilling, a revenue and compliance issue, may happen when a coder accidentally uses multiple codes instead of a single code for a procedure, potentially putting themselves at risk for insurance fraud.3 hbRecon reduces overbilling through its ability to identify plausible miscoded DRGs and maximize procedure coding with higher or lower-weighted DRG codes where appropriate.

Missed Reimbursement Opportunities: A service, procedure, or condition (a CC or MCC) during a patient encounter being left out of a claim due to a missing code or skewed data can lead to a loss in revenue. hbRecon’s phased approach to integrating clinical registry and claims data results in increased reimbursement driven by identified factors in clinical registry data. 

Faulty Re-Bill Processes: Faulty rebilling occurs when a claim is rebilled due to a medical or coding error. In Phase 3 of the hbRecon integration – reconciliation and process review – cases are reviewed by the clinical team and then submitted for secondary review by the hospital coding and compliance teams. This process will vary from site to site and network to network, but one of the primary objectives of this is to recode and re-bill as indicated by the findings.   

The Importance of Comprehensive Medical Coding Audits for Heart Care

These challenges with claims data collection due to coding gaps, and subsequent pitfalls in revenue and compliance, point to the necessity of undergoing comprehensive coding audits that can successfully identify coding gaps in cardiovascular care and address them to support revenue cycle optimization. 

However, claims audits focused on financial data inherently miss the other side of the coin – clinical registry data. 

hbRecon maximizes accurate revenue capture through the integration of hospital clinical registry & coding data sources. Through this integration, hbRecon can identify cases where coding may be incorrect and identify thousands of dollars in services per case that would have otherwise gone unbilled. With claims data, if conditions are not coded, such as Acute Heart Failure, it is not possible to identify them. With clinical registry data and hbRecon, we can extrapolate those values, maximizing the revenue capture.

Because clinical registry data uses discrete data elements that contain detailed clinical information about patients, diagnoses, procedures, and outcomes, and claims data uses a coded data source that includes details about procedures performed, diagnoses, medications prescribed, and associated costs, hbRecon provides a more comprehensive and accurate assessment of healthcare quality, outcomes, and financial performance. The hbRecon platform then employs an algorithm to determine a recommended DRG code using this combined dataset. 

The higher levels of specificity produced by hbRecon lead to improved revenue capture through more accurate documentation and coding through education and process-improvements; enhanced quality and efficiency of care delivery; and a better reflection of patient acuity, all of which benefit the cardiovascular population. 

hbRecon: The Combined Impact of Combining Clinical Registry Data with Claims Data 

hbRecon’s integrated approach to coding audits is a valuable tool for increasing revenue capture as it relies on both the discrete data elements found in clinical registry data as well as the coded data sources found in claims data. 

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

1. Conifer Health Solutions. (2023, August 7). Common coding challenges hospitals face and how to fix them.  Healthcare Financial Management Association.  https://www.hfma.org/revenue-cycle/coding/common-coding-challenges-hospitals-face-and-how-to-fix-them/

2. MGMA. (2023, March 23). Bottom line impacts from revenue cycle staffing challenges.  MGMA. https://www.mgma.com/mgma-stats/bottom-line-impacts-from-revenue-cycle-staffing-challenges

3. Physicians Revenue Group. (2024, August 26). What is Unbundling in Medical Billing? | PRGMD. Physicians Revenue Group. https://prgmd.com/what-is-unbundling-in-medical-billing/

4. Enhancing CC and MCC Code Capture: Three Real-World Scenarios for Maximizing Reimbursement Revenue. (2024, November 25). heartbase. https://www.heartbase.net/news/2024/11/25/enhancing-cc-and-mcc-code-capture-three-real-world-scenarios-for-maximizing-reimbursement-revenue/

Heartbase, Inc. Certified in ACC-NCDR EP-DI v3.0

CHICAGO, IL – We are excited to announce that heartbase™ is officially certified by the ACC-NCDR for Version 3.0 of the EP Device Implant Registry (EP-DI) Database. 

On January 29th at 12:30 PM CT, heartbase clinical specialist Carmen Ernst, RN, BSN, will hold a special training class covering the ins and outs of this version. Heartbase customers can click here to register. Heartbase staff highly recommends that users attend this session or view the recording.

From the ACC-NCDR website:

“EP Device Implant Registry™ establishes a national standard for understanding patient characteristics, treatments, outcomes, device safety and the overall quality of care for ICD/ CRT-D and select novel pacemaker procedures, while also delivering benchmarking data. Participating facilities can submit data for pacemaker procedures or submit data for ICD/ CRT-D procedures or submit data for both. The registry plays an important role in providing data-driven knowledge for optimizing patient care.”

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 EP-DI cases are correctly coded and billed, maximizing reimbursement.
  • Planned hbAnalytics updates to include new measure reporting and associated breakout reports.

If you’re an EP-DI 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.

Our primary major business lines are the following: hbCOR, Data Capture & Reporting; hbAnalytics, Realtime Clinical & Financial Dashboards; hbRecon, Coding Reconciliation & Revenue Generation; & hbNote, Data First Structured Reporting.

Real User Insights: Evaluating the Impact of hbRecon at Three Hospitals


Discrepancies between coding data and clinical registry data can significantly impact reimbursements in a cardiac services department — yet many health systems are unable to recognize these missed revenue opportunities without a comprehensive coding audit.

The hbRecon solution was selected by the following three hospitals to help identify and resolve these discrepancies in their cardiac services billing departments. Here, we share their experiences and explore how hbRecon’s clinical registry data-based audits helped build a more profitable and efficient cardiac services department in each organization.


Evaluating the hbRecon Impact: Explore Three User Experiences

1. How does your hospital use clinical registry data?

  • Jerod Weimer, Bakersfield Memorial Hospital: We use the registries to measure, monitor, and improve our patient care and outcomes.
  • Kerry Webb, Chandler Regional Medical Center and Mercy Gilbert Medical Center: We use our data for measuring performance, quality goals and performance improvement.
  • Beth Kennalley: To measure and monitor clinical performance, quality goal performance, and performance improvement activities.

2. What do you find most valuable about collecting registry data?

  • Jerod Weimer, Bakersfield Memorial Hospital: The ability to keep our “finger on the pulse” of the systems involved in our patient care and program performance.
  • Kerry Webb, Chandler Regional Medical Center and Mercy Gilbert Medical Center: The data helps to identify any processes that may need to be improved and usually end up uncovering other things that can use improvement.
  • Beth Kennalley: Identifying performance opportunities and excellence.

3. How has hbRecon fit into your current processes and workflows?

  • Jerod Weimer, Bakersfield Memorial Hospital: hbRecon has allowed us to expand the awareness and performance of our documentation and interdepartmental working relationship by closely tying the clinical data to the administrative data.
  • Kerry Webb, Chandler Regional Medical Center and Mercy Gilbert Medical Center: It fits in looking at and reviewing the data when I have a chance. Sometimes, it is right after it is uploaded, and other times, it takes a week or two.
  • Beth Kennalley: hbRecon is a monthly review of any abstraction and coding differences on both our Open Heart and CathPCI cases, and has taken less and less time as we have improved performance in both areas. It allows me to quickly and accurately review both data sets to ensure they accurately reflect the case that was performed.

4. What do you find most valuable about using hbRecon?

  • Jerod Weimer, Bakersfield Memorial Hospital: hbRecon’s most valuable impact has come from increased accuracy in both clinical and administrative documentation.
  • Kerry Webb, Chandler Regional Medical Center and Mercy Gilbert Medical Center: hbRecon has helped identify documentation issues on the physician’s end. It has also helped our coding team to improve their system when it or the people are combing through the charts.
  • Beth Kennalley: The ability 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 and find multiple errors in a short amount of time, and to submit this information for correction in a timely manner. The tool has allowed us to be reassured that our billing is accurate in these areas.

Realize These Financial and Operational Benefits in Your Organization

Each of these hospitals’ experiences highlights the critical importance of accurate coding for cardiac services, as well as the challenges of comprehensively capturing the services provided during each episode of care. The hbRecon toolkit equips health systems with a more granular audit based on clinical registry data to reduce under and over-billing, accurately reflect patient acuity and case mix index (CMI), and drive proper reimbursements. Through step-by-step improvements in coding quality, with a core focus on enhancing interdepartmental collaboration, hbRecon is helping health systems maximize accurate revenue capture for their cardiac services.

Want to learn more? Schedule a demo to discover how hbRecon can improve cardiac services profitability in your health system.

Heartbase, Inc. Officially Supports the STS Adult Cardiac Beta Blocker & General Thoracic Neo-Adjuvant Supplemental Forms


CHICAGO, IL – We are excited to announce that heartbase™ officially supports the STS Adult Cardiac Beta Blocker Supplemental Form for v4.20.2 and General Thoracic Neo-Adjuvant Supplemental Form for v5.21.1. On April 30th, heartbase clinical specialist Carmen Ernst, RN, BSN, will hold a special training class covering the ins and outs of these optional updates. Heartbase customers can click here to register.

From the STS:
“Advances in medicine, technology and research interests has generated the need for The Society of Thoracic Surgeons (STS) to collect additional data from sites related to the already existing registries: Adult Cardiac Surgery Database (ACSD), General Thoracic Surgery Database (GTSD), and Congenital Heart Surgery Database (CHSD). This information is needed in a timely manner and cannot wait until the registries have completed a full data specification upgrade. To facilitate obtaining this data as soon as possible, the STS is providing REDCap web pages and is asking sites to voluntarily use these forms for recording the supplemental data.

Many sites have expressed the desire to not have to switch to a different platform for recording any additional information, preferring to keep all data entry within their current vendor software. For this reason, STS is making the specifications for these data collection forms available to software vendors who are already certified on the latest versions of each registry so the new fields can be incorporated into their existing software. There is no requirement from the STS for vendors to incorporate these fields into their software and doing so is completely voluntary.”

Participation using hbCOR offers:

  • A single location to capture and audit both standard and supplemental STS ACSD & GTSD variables.
  • Ability to run AD HOC reports using the hbQuery Tool for the supplemental fields.
  • Facilitated submission to REDCap – vendors must submit the supplemental data to the STS on behalf of the organization.

Please contact the heartbase Sales Team (sales@heartbase.net) with any questions about adding this optional form to your heartbase hbCOR instance.


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.

Our primary major business lines are the following: hbCOR, Data Capture & Reporting; hbAnalytics, Realtime Clinical & Financial Dashboards; hbRecon, Coding Reconciliation & Revenue Generation; & hbNote, Data First Structured Reporting.

Request a Demo Want to see how we can help you with collection and reporting?