Interdepartmental Cooperation Will Help Ensure Success of APCs

The waiting is finally over ambulatory payment classifications (APCs) have arrived. As facilities start using the new outpatient prospective payment system (OPPS), they realize that the various hospital departments must rely heavily on one another.

Interdepartmental communication is the single most important thing that APCs will require, says Jack Turner, MD, PhD, medical director for documentation and coding compliance, healthcare financial services, for the emergency department (ED) staffing company TeamHealth in Knoxville, Tenn.

Traditionally, facilities have prepared bills in a disjointed fashion, with different departments sending their bills at separate times, Turner says. Some departments combine everything from the procedure to the nursing time to the medications in one charge, while others itemize. Because of this inconsistency, few hospitals have a good understanding of the total reimbursement for specific services.

APCs require hospitals to cooperate not only on the front end, sharing information to set up a coding and billing system, but also on the back end, to monitor the claims history and make changes to the system. Much of the responsibility for this communication falls on the APC task force, or implementation team, which should share information about procedures with everyone touched by the new system.

Nobody really knows how much one department affects another, says Caral Edelberg, CPC, CCS-P, president of Medical Resource Management in Jacksonville, Fla. They think, Im a coder. What do other people care how Im coding? Well, the business office needs to know because theyre dealing with rejections on codes and modifiers.

When a claim gets denied, billers will need coders help to determine why. They wont know whether the coders arent following the rules, the fiscal intermediary (FI) made a mistake, or the coders and FIs are working with separate sets of rules that dont match.

Providers also need to interact with the coders. If denials are due to inaccurate or insufficient documentation, clinicians must make changes. They wont know what to do unless they understand what coders and billers need to accommodate the new APC rules. In most instances, the head of the coding department should provide the feedback, but rank-and-file coders will need to keep that person apprised of recurring coding problems.

Working Together

Most hospitals already should have a well-organized APC task force that includes members from each group affected by the new payment method. If your group doesnt already have a high-level administrator such as a chief financial officer at the helm, now is the time to recruit one, Turner says. To more easily sell the idea of cooperation to departments not used to such collaboration, the APC chief should be someone in a position to make demands, not requests. A nurse manager cant do it. He or she may [...]

- Published on 2000-09-01