As healthcare moves from a volume- based to a value-based system, revenue integrity is paramount to
success. It is generally recognized that coded
data generates much of the information that is
used to determine performance and outcomes.
Most healthcare entities do a good job
establishing coding compliance programs that monitor and ensure coding
accuracy and compliance. Revenue
integrity, however, is often overlooked.
Low coding and billing denial rates
lull many organizations into a false
sense of security. Limited resources,
Hospitals and physician practices alike
must be astute in improving processes to opti-
mize outcomes and control costs to achieve and
sustain positive financial results in the world
of value-based purchasing. Outcomes and
costs are rooted in clinical information quality,
coding accuracy, appropriate charge capture,
and timely compliant billing. Such monumental
tasks require consistent root cause analysis on
issues that impede the revenue cycle. Revenue
integrity must be a formal, centralized process
that is constant and inclusive of all departments
and individuals who affect the revenue cycle.
Revenue integrity team
Data from 2017 will be used by CMS to determine payments or penalties in 2019. There is
still time to ensure that the data used to assess
performance is accurate and favorable by
establishing a Revenue Integrity department
or designating a revenue integrity leader with
knowledge of clinical documentation improvement, coding (ICD- 10, CPT, and HCPCS) and
the correlation of charge capture, and revenue.
It will also be necessary for revenue integrity analysts to carry out the procedures to
identify trends and issues that negatively
impact revenue. A revenue integrity core team
should be formed that includes representatives
from Patient Access, Coding, Billing/Finance,
the Charge Description Master, Compliance,
by Annette Sullivan, RHIA
» The impact of revenue integrity on value-based healthcare is often overlooked.
» Revenue integrity must be a formal, centralized process that is constant and inclusive of all departments
and individuals that affect the revenue cycle.
» The integrity of your data in 2017 will determine the payments you receive and the penalties you incur in 2019.
» Track and trend issues, determine the root causes, and implement solutions to improve efficiencies.
» Develop an audit plan to reduce days in AR and mitigate risks of claims denials.
Annette Sullivan ( firstname.lastname@example.org) is Senior Manager with the
Coker Group in Alpharetta, GA, and an AHIMA-approved ICD- 10 CM/PCS trainer.