EXECUTIVE SUMMARY
Frequent changes within the outpatient prospective payment system (OPPS) have kept reimbursement managers of hospital-based same-day surgery program scrambling to keep their internal systems up to date. One solution is to create a position specifically to monitor changes and implement updates.
* A full-time ambulatory payment classification (APC) coordinator is justified most easily by a facility with many ambulatory services that are complex.
* Other options for coordinating changes include subcontracting with a consultant or making APC coordination part of one staff person's job. Whoever handles the coordination should have the authority to work with a variety of departments and people.
* According to some sources, the coordinator does not have to have a coding background or clinical experience.
With the multiple changes the outpatient prospective payment system (OPPS) has experienced since its implementation in August 2000, many hospital-based same-day surgery program staff wonder how many items have fallen through the cracks and resulted in claim denials.
Frequent transmittals of changes and ambiguous language have made it difficult for the staff at Asante Health System in Medford, OR, says Rick Fernandez, MHA, reimbursement manager for the system.
'Although several people share the function, there is no clear coordination. I am sure that we've missed things that have kept us from implementing timely changes in our system,' he says.
For this reason, his health system is evaluating a new job position that will coordinate ambulatory payment classification (APC) activities.
'From January 2001 to October 2001, there were 55 transmittals of changes related to the OPPS,' says Valerie A. Rinkle, MPA, executive director of Hospital Resource Management, a Medford, OR-based consulting firm that specializes in reimbursement issues. 'When you are dealing with this many changes that need to be reviewed and addressed within your own program, it may be necessary to develop a position that is solely responsible for coordinating APC issues.'
The job description for APC coordinator should include more than just monitoring changes in the OPPS, Rinkle says.
'An APC coordinator should read transmittals, undertake whatever research is necessary to ensure that the changes are interpreted correctly, develop a work plan to implement changes within the facility, and implement the plan utilizing whatever departments are affected,' she says.
The APC coordinator at Nebraska Methodist Hospital in Omaha was put into place about six months before the implementation of OPPS, says Mary Meysenburg, RHIA, CCS, service executive of medical records. At the time, the primary responsibility was to coordinate all education and activities needed to be ready for OPPS, she says. Now, the coordinator monitors all change transmittals related to OPPS and monitors the facility's internal records to identify causes of claim payment delays or rejections, Meysenburg adds. Once a problem is identified, the coordinator is responsible for working with the appropriate people and departments to correct the problem, she says. 'Sometimes it's a matter of education, and the coordinator provides that education,' she adds.
An APC coordinator is probably a good position to evaluate if your facility has several outpatient services, such as radiation oncology, sleep lab, or ambulatory clinics, in addition to same-day surgery, says Rinkle. If your facility only has same-day surgery and basic outpatient radiology and lab services, it is harder to justify the expense of a dedicated employee, she adds.
Same-day surgery programs in hospitals that don't have multiple ambulatory services do have several options to efficiently handle the changes that must be made, Rinkle suggests. The business office manager, reimbursement manager, chief financial officer, or controller can act as the coordinator as part of his or her job with specific people identified throughout the different departments to handle implementation of changes, she says. The key is to make sure that there is someone who coordinates and follows up on changes that need to be made, Rinkle adds.
'Facilities that are a part of a larger network can get together to fund an APC coordinator position that will monitor changes and implement plans to update systems for all members of a network,' she says. 'Smaller facilities can subcontract some or all of the responsibility to a consultant who specializes in reimbursement issues.'
You can find a subcontractor in several ways, Rinkle says. 'Check with professional associations and network with your peers,' she suggests. (See source box, at right.) 'Be sure to check references from other programs using the subcontractor for the same job you want him or her to do,' Rinkle adds.
If you do decide to create an APC coordinator position, look for a 'hound dog' to fill the slot, Rinkle suggests. 'This person needs to be diligent, to be persistent about ensuring follow-through, and to have a good understanding of how departments work together,' she says.
A good APC coordinator also needs to have the authority to direct activities that cross departmental lines, she adds.
While an employee who oversees activities related to changes in OPPS, either full time or as part of another job, doesn't need to be a coding expert, he or she should understand the basic principles of coding and be able to talk with coding experts when needed, Rinkle says.
A clinical background is not necessary and, in some cases, may be a potential problem, she says. 'Someone with a clinical background might not see missing information in documentation,' she points out. 'A clinical person might read a chart and understand how the provider got from point A to point C without having to see point B since he or she already knows what happens in between.' A nonclinical person will look at the same chart and ask, 'What did you do to get to point C?'
While Asante Health System's staff recognize importance of an APC coordinator, there are several issues that must be evaluated, Fernandez says. 'We are taking a close look at cost vs. benefits of having one dedicated position coordinating everything, and we are trying to decide what level of skill we need to hire,' he says. 'The big question is whether or not to hire an expert in the area or move an existing employee into the position and provide training.'
Meysenburg says her facility's administrators did believe that a good knowledge of coding was important for this position, so they looked for someone with a coding background. 'This person's experience ensures that she can interpret the documentation in relation to the codes used on the claim,' she explains.
Although her facility has not performed a formal study to evaluate the benefits of the APC coordinator position, Meysenburg says that by watching the days in accounts receivable and the reports of claim payments delayed or denied, she can tell that the position is worthwhile.
'If we didn't have a knowledgeable person responsible for monitoring OPPS changes and how we code claims, many delayed or denied claims would have had additions or deletions of codes made without anyone checking to see if we were in compliance,' she says. 'This way, we know that our claims are coded accurately and we are ensuring that we're paid correctly.'
SOURCES AND RESOURCEFor more information about ambulatory paymentclassification coordinators, contact:* Rick Fernandez, MHA, Reimbursement Manager,Asante Health System, 100 E. Main St.,Medford, OR 97501. Telephone: (541) 608-5099.* Mary Meysenburg, RHIA, CCS, Service Executiveof Medical Records, Nebraska MethodistHospital, 8303 Dodge St., Omaha, NE 68114.Telephone: (402) 354-4667. E-mail: mmeysen@nmhs.org.* Valerie A. Rinkle, MPA, Executive Director,Hospital Resource Management, 30 S.Barneburg, Medford, OR 97504. Telephone:(541) 608-9845. E-mail: vrinkle@hrmlc.com.For names of consultants who provide help in managingoutpatient reimbursement changes, contact:* Healthcare Financial Management Association,Two Westbrook Corporate Center, Suite700, Westchester, IL 60154-5700. Telephone:(800) 252-4362 or (708) 531-9600. Fax: (708)531-0032. Web site: www.hfma.org. A printedcopy of a resource guide is available only to subscribersof the association's monthly publication($100 per year), but an on-line version is availableat no cost at www.hfma.org/publications/HFM_On-Line_Resource_Guide.htm.
