Ob-Gyn Coding Alert

One of the major areas of lost revenues in an ob/gyn practice is services and procedures performed in the hospital but never billed for, says Jan Rasmussan, CPC, coding consultant and instructor for Med Learn, a medical practice management training and consulting firm in Eauclair, WI. Its the one area that is difficult for the ob/gyn clinic coder to track. Actually, no one seems to know exactly how extensive the problem is or exactly how much revenue is lost, but in talking with a number of consultants, ob/gyn practice managers and coders and ob/gyns, all acknowledged that it was an area where most practices could use help.

Most ob/gyn offices are quite familiar with the problem. Typical scenarios include: an ob/gyn rushes to the hospital at the end of a busy day to deliver a baby. Theres no problem there, the patient is covered under a global ob charge. But following the delivery, the physician heads up to see a gyn patient on a medical floor, and after a quick report from a nurse, decides to perform a minor procedure on the patient. Just as the ob/gyn is about to leave the hospital, he or she gets a page from the ob floor and ends up heading back to the ob department to address a problem with a different ob patient who delivered the night before. By the time the doctor leaves the hospital, his or her office is usually closed and the staff has gone home. So the ob/gyn also heads home.

The next day begins with rounds and then a full clinic schedule. By the time the doctor takes a break, the procedure performed on the gyn and ob patient the night before has been forgotten and thus is never brought to the attention of the coding staff. Clinic coders at best only have limited knowledge of what goes on in the hospital if the physician does not bring the information back to the clinic.

Hospital Activity Tracking Tips

How ob/gyn practices track hospital activity varies greatly based upon the size of the office, the needs of the physicians and other healthcare providers (CNMs, NPs PAs) and their relationship with the hospitals. We found a number of different methods being used to track hospital activity with varying degrees of success.

Method #1: Many practices are still using a form (often a small card) in which the physician records the name of the patient, the days the patient was seen in the hospital and what was done for her. Some of the forms have commonly used CPT and diagnosis codes on them for easy reporting. The physician records the data and brings the cards back to the office staff at the clinic. In some ob/gyn practices, this form is supplemented with the admission face sheet from the hospital chart. The success of the system requires that the physician has the form, completes it at the time of service, and returns the form to the clinic office staff.

Subscriber Benefit: For a free fax sample of a hospital activity recording card, or to purchase the card in easy to use booklets with tear off cards call OCA at 800/508-2582.

Method #2: The hospital provides the clinic with a carbon copy of the face sheet and discharge summary and, in some cases, written or dictated progress notes and operative reports. The success of this system rides on the coder being able to obtain these records in a timely fashion and determine from them the services provided.

Method #3: The coder simply corners the physician once a day and immediately after a weekend and quizzes him or her on the previous days hospital activity. This system apparently works well in a small practice where the ob/gyn is accessible to the coder.

Method #4: At the other extreme, some practices have attempted to solve the problem with high tech answers, using computer links to hospital medical records. This demands a certain amount of cooperation and MIS sophistication from both the clinic and hospital. A few practices are even experimenting with hand held computers that physicians carry to the hospital with them.

Create a System that Works

According to Rasmussan, the solution to capturing lost revenue from hospital activity is not what you do but how you do it. She suggests that ob/gyn practices focus on the big goal of accounting for this revenue and creating a system that works for them regardless of whether it uses cards, computers or conversations. Here are some suggestions for evaluating and creating a system for your practice.

1. Identify the Need. Before you do anything with your present system, first identify if you have a problem of lost revenue. Are you hearing about hospital activity without any documentation that will allow coding? Show your physicians a record of recently billed hospital activity and see if they have any sense of whether or not everything is being captured. You may need everyones cooperation to do a short study in which providers keep a log of everything they do during a hospital visit. You can then compare this log to what youve historically been coding. But above all try to establish a benchmark so you can measure whether any system changes make a difference.

2. Understand the Problem. Before making any changes, make sure you understand the problem fully. Dont simply write off the challenge as a "people" problem. Most organizational consultants point out that these are not really people problems but "systems" problems. Create a flow chart that shows what is currently happening and identify the areas of concern. For example, if losses occur during weekend hospital visits, try to identify what barriers are prohibiting getting the data back to the office.

3. Obtain Cooperation and Input From Staff. Rasmussan points out that once you have identified and understand the problem, it is essential that everyone, especially the physicians, have input into the solution. This is where you need to be a salesman. Your selling point is that this is about dollars. If you can demonstrate a potential revenue gain, which can benefit everyone in the practice, you will stimulate interest in participating in the solution. Also, you will find people more cooperative if the problem is presented as a systems failure and not a personal one.

4. Create a System that Works for Your Practice. Starting with a clear objective (i.e. to capture 100% of hospital activity), begin to create a system that addresses the problems and barriers youve identified. Here are some concrete suggestions from ob/gyn coders, practice managers and physicians.

Have someone in the office watching the call schedule and checking with physicians about activity

Create a pocket-sized tracking form that has both CPT and ICD-9-CM codes and check off boxes

Have someone designated to follow up on weekend activity on Monday

Develop a relationship with your hospitals to obtain all dictation and progress notes

Create a phone recording system so the physician can simply call a number and report activity before leaving the hospital at any time of day or night without having to complete a form or remember to bring it back.

Provide a weekly list of billable hospital activity for each physician to check against what they actually did.

5. Assess Your Progress. Clearly, the system you design will have to compliment the personality and style of your practice and its caregivers. The important thing is to have a process in which you can measure the results. As you implement a new procedure, try it for a period of time and then compare the results to the benchmarks you established before any changes were made. This way you can demonstrate that your hard work produces desired results.

Editors Note: Although throughout this article we use the term ob/gyn for simplicity, however, we realize that there are many other caregivers that these items can apply to, including: Certified Nurse Midwives, Nurse Practitioners and Physicians Assistants.