Revamping Radiology Workflows for Improved Billing Accuracy: A Large Hospital’s Experience

After multiple delays, healthcare organizations across the country are now required to code diagnoses and procedures using the 10th revision of International Statistical Classification of Disease and Related Health Problems, better known as ICD-10. Implementing this new coding system has been a pain point for many hospitals. With more than 68000 codes (up from ICD-9’s 14000), ICD-10 brings a variety of mapping and other technology issues that can hinder provider workflows and interfere with timely reimbursements. But with the October 15, 2015 deadline now passed, the onus is on hospitals, both in the business office and in the treatment room, to find creative ways to make it work. 

Leigh Shuman, M.D., a radiologist at a large hospital system in Central PA, says that their unique partnership for radiology services resulted in coding discrepancies under the new ICD-10 classifications—things that could get in the way of timely reimbursements. He talked with Healthcare Informatics about the nuances of today’s healthcare organizational structures, ICD-10 coding and reimbursement challenges, and how the addition of system software tools are helping his organization address coding discrepancies without disrupting clinical workflow.

What challenges was the hospital facing with regards to coding discrepancies?

Shuman: One challenge we faced was our organizational structure. I do not work for the hospital. I work for a practice that has a contract with a local hospital to provide radiology services. So when we bill for imaging studies, the hospital issues a bill for the technical component and we bill for the professional component separately through our own billing office that we run and operate. We are our own billers.

For example, if a patient came to the hospital with a cough and fever and a chest X-ray is ordered, the hospital bills that under the ICD-10 code for cough and fever. If I read the chest X-ray and diagnose pneumonia, we bill that under the ICD-10 code for pneumonia. Our report must contain sufficient detail so our coding people and coding software can get enough information to generate that ICD-10 code. It’s a challenge. So we had this big issue: how can the billing office let us know that they’ve got a report they can’t code because it doesn’t contain the information they need to code it?

Historically, how did you work around that issue?

Shuman: It was generally handled with a phone call or an email. You’d get an email through the hospital’s secure email system saying, “Can you please look up so and so? Your report doesn’t contain the information we need or there may be a mistake.” That email system is on a separate computer system than our PACS. So you’d have to actually move your chair to a different set of screens and keyboards to read the email, then go to another one and somehow transfer the information to PACS so you can look up the person, look at the report, and then dictate an addendum as needed. It was really cumbersome.

Why implement additional software to improve that process? What were your goals for the implementation? Shuman: We’ve been using Conserus Workflow Intelligence since 2010—we were one of the earlier adopters. This was back when people called it peerVue or QICS. With the QICS, the C stands for communication. And we had learned that the product was great for setting up new well-defined workflows that you might need to establish—on your workstation. So our goal was to find a way that the radiologists could communicate with the billing office without interrupting our work. We wanted to be able to get a notice that we had to deal with a particular report while we were sitting at the PACS workstation, so we could solve the problem there instead of going between different computers. So we created a custom workflow that is generated by the billing office when they come across a coding discrepancy.

Was the implementation process difficult?

Shuman: No. Creating the workflow in Conserus is very easy. The biggest challenge was finding the right channel between our billing office, which is not directly on the hospital network, to facilitate our communications. We are connected to the hospital through their VPN in order to get billing information since the case is done there, they have the information, and it has to be transferred to us. We have that connection, but it wasn’t a simple thing to include the billing office. But we were able to create a way to maintain a secure server connection between our billing office and the hospital so we didn’t violate anyone’s privacy rules and were still able to interface Conserus with a computer in our billing office so we could make communications more seamless.

How did you get key stakeholders on board for this implementation?

Shuman: It wasn’t difficult—everyone liked the idea. The billing office liked it because their emails would conveniently get ignored for long periods of time. And we radiologists liked it because we hated being interrupted and having to stop what we were doing to go look at those emails. We knew we were going to have issues with the reports that didn’t have the right information for billing, particularly as we moved over to ICD-10. So this solution was an easy sell. You didn’t need to rely on a radiologist to trigger the communication, so they were happy about that. The billing office was tickled because they wouldn’t have to chase us down. Everyone has been very happy with it.

How does the implementation fit in with the radiologists’ existing workflow? Shuman: It fits in well. We use Conserus for many other things—and we’re used to getting the pop-up windows in our daily peer reviews, in our consultations about difficult cases, and a dozen other common workflows. This quickly became part and parcel of what we do on the system every day. You just get a pop-up window that says, “You’ve got this case. Can you please address this issue?” We can put a snooze on it if we need to when we’re busy. You don’t have to act on it instantly. But it’s there and reminds you to take care of it.

The nice thing about Conserus is that it positively reinforces itself. The more you use the system, the more comfortable you become using the system. There’s not a lot of training required to get people to use it. It’s very good at giving people gentle reminders that you have work to do, whether you are doing a peer review or dealing with a billing issue. It’s simple to use, it works well, and everyone is happy with it.