Meeting EP Administrators’ Challenges: Suggestions on Best Business Practices in the EP Lab

Salwa Beheiry, RN, CCRN, Director, Electrophysiology and Arrhythmia Services, Sutter Pacific Heart Centers, San Francisco, California
Salwa Beheiry, RN, CCRN, Director, Electrophysiology and Arrhythmia Services, Sutter Pacific Heart Centers, San Francisco, California
While electrophysiologists and clinical staff deal with the critical physiological aspects of electrophysiological (EP) procedures, the EP laboratory’s administrators must handle critical concerns of a different sort: business issues that determine the financial viability of their programs. This article will address some of the most common challenges that can impact the fiscal success of any EP program. Some solutions to these challenges are suggested, based on the successful experiences shared by a group of EP administrators who met for the purpose of discussing these issues at the Administrators Advisory Board sponsored by Biosense Webster, Inc. 1. Operative Reports Complete operative reports and reports that are prepared with the needs of coders/billers in mind are very helpful in streamlining the process of coding and in conveying the information clearly to payers. One way of accomplishing this is to create a template that includes the following: • Description of diagnosis and ICD-9 • CM Diagnosis Code for each procedure performed and its corresponding CPT® Code • Any other pertinent information that will clarify the information needed by coders, billers, and payers as indication for the procedure. Operative reports that are incomplete or contain errors create a number of problems for the EP lab administrator. The diagnosis listed in the report must always match the procedure in order to gain approval for payment. Only the diagnosis that is being treated by the procedure should be listed in the operative report. If a patient has a number of comorbidities, those should be described in the history. Some EP labs have programs with drop-down menus that list diagnoses with corresponding CPT codes. It is also helpful to involve the EP clinicians when developing the template for the operative report. In our experience, physicians who were involved in the development of the operative report are more likely to complete it correctly. 2. Coding and Billing Coding is another critical challenge that all of us face. Some hospitals have cardiology-specific or cath/EP-specific coders, which is a very useful approach. However, others use outsourced coding, which makes it difficult to communicate directly with the coders. When possible, it is helpful to meet with the hospital’s coders and those in charge of the hospital’s charge description master. Regular (semi-annual or annual) meetings with the coding team are helpful to continually improve their understanding of EP and thereby simplify their job. Coders who cover numerous specialties may not be able to correctly correlate diagnoses with procedures, which leads to the incorrect coding of procedures. To address such situations, some administrators meet with coders to explain the EP terminology and procedures; some even invite the coders to observe a procedure so that they will appreciate its complexity and understand the different steps that comprise the whole. With rapid and continuous advances in the equipment and techniques used in procedures such as ablation, it is important to keep staff, coders and billers abreast of these new techniques and technologies. Regular auditing can help to reduce the impact of incomplete or incorrect reports. EP lab administrators can take various approaches to auditing. At our center, the EP staff audits the report before it goes to the hospital coder; the reverse is done at other centers, with the lab administrator checking it after the coders complete their work. Accurate coding is also confounded by frequent changes in CMS guidelines and reimbursement rules. Keeping current with CMS (Centers for Medicare & Medicaid Services) regulations is an ongoing challenge for all. Changes occur every six months and new additions or restrictions are announced frequently. In most hospitals, coders receive regular updates from the hospital’s finance department in order to keep abreast of CMS changes and other applicable compliance issues. In these situations, the coders routinely inform the EP lab of changes. Ideally, EP administrators network with the coders, operating as a team and updating each other on pertinent developments. There are also software programs available such as CodeCorrect that provide automatic updates. Whether the hospital provides these updates or not, it is vitally important for both administrators and staff to keep up with new CMS changes. Since these changes are usually complicated, some EP programs retain a consultant whose purpose is to help the EP administrator navigate through the complex CMS issues. It is worth the investment of time for EP or cardiology administrators to contact various payer organizations to clarify coding questions and to educate payers on specific issues such as whether a particular procedure is investigational or has become standard of care. Whether done by coders or the EP lab staff — clinical or administrative — there is immense value in educating case managers and the medical director at the payer organization. It is a good practice to periodically share with payer organizations literature describing new procedures and technologies so that they become aware that these are not investigational but have become widely accepted and frequently performed. 3. Scheduling and Staffing Scheduling conflicts and staffing problems are not only a cause of frustration but can also prevent the EP lab from establishing positive financial milestones. Improved communication with physicians is key to meeting this challenge. The administrator must be firm about scheduling, notifying physicians when the lab is available for their case(s), and emphasizing punctual start times for completion. Some busy labs have added a second shift so that the lab is available and staffed from 7:00 a.m. until 8:30 p.m. A dedicated staff is crucial to running an efficient operation in the EP lab. Since the equipment utilized is complex, the staff must be knowledgeable about its use and the procedures as a whole. It is not practical to borrow a nurse or technologist from another area to fill in the EP lab. 4. Financial Concerns Revenue and reimbursement depend on a complete and comprehensive charge description master to manage and update the EP lab’s charges. While some hospitals have a coordinator for this job, it is often the responsibility of the administrator to maintain this important tool. There are software programs available to help with this; although they may seem to be expensive, any cost can likely be recouped several times over by assuring correct and maximum allowable billing. To assure accuracy, some hospitals perform a 100% audit-reviewing of every chart. While this may seem labor intensive, it is probably a more cost-effective procedure than having to revisit denied requests weeks or months later. It may also generate faster payment. Therefore, it is essential that the charge description master be current and correctly implemented. With most charges now procedure based, questions can arise when an ablation is performed in an OR that still uses time-based charges. In such an instance, negotiation is required with the OR and hospital administrator. The reasoning is that if EP staff and EP equipment are used, the ablation should be a procedure-based charge, even if done in the OR. Another question that can impact efficiency in the EP lab is the level of sedation during EP procedures. In many labs, the EP physician requests the anesthesiology department to handle deep sedation. In those situations, the EP lab doesn’t bill for it; the anesthesiology department charges for it separately. That is actually less expensive for the EP lab than using its own RN. Under a new law in Ohio, nurses are prohibited from administering or monitoring deep sedation.1 Those labs will have to use anesthesiologists, nurse anesthetists (CRNAs) or nurse practitioners (NPs) certified to handle deep sedation. However, since it can be difficult to get an anesthesiologist to come to the EP labs on a regular basis, scheduling can become an issue. Many labs now train RNs to administer moderate sedation, which is usually adeaquate in managing the patient during EP procedures. Questions can also arise regarding hospital charges. Most hospitals have a formula for determining charges for each procedure. However, sometimes the lab administrator will lead the process. In such cases, a team from finance/patient accounts can gather cost data in the area and also check contracts with insurance companies. It is important to make sure that the lab’s cost of supplies is captured. An ongoing challenge is the payer’s denial of claims or reduction of submitted charges. Usually the hospital’s finance department handles communication with payers; lab administrators seldom talk directly to payers. The extent of our involvement is to review the chart to discern if there were coding mistakes or other reasons why the claim was denied. Problems can arise when there is confusion over whether a procedure is performed as an inpatient or outpatient procedure. For example, physicians’ offices frequently overlook details such as doing a procedure on an inpatient basis when the payer stipulates it as an outpatient procedure, making a big difference in payment. If a procedure is an outpatient procedure, it is important for payment criteria that the patient is discharged within 23 hours of admission. We work with our NPs to make sure that this happens, if medically acceptable of course. If one payment per month is corrected, using the NP will be a good approach. Hospitals have different approaches to billing as well. In some hospitals, a staff member who is in the room for the whole procedure does the billing. Others prefer to have the coders do the billing, because they are more current with changes and codes. There are pitfalls in having the billing done later by someone looking at the chart; they will likely miss a lot of charges. It is also preferable to use dedicated EP staff rather than a floater — a person familiar with EP procedures and terminology should do the billing in order to be complete and accurate. The issue of a high ratio in cost vs. reimbursement is another ongoing challenge, so how can lab administrators control labor and device costs? A number of us communicate with vendors directly instead of relying on the purchasing department. In order for this to be effective, we must familiarize ourselves with contracts, pricing, and GPO agreements. Technology dictates what equipment we use, and selection of devices is driven by the physicians. Regarding device cost, involve your physicians in cost discussions. Many are creatures of habit and are not necessarily aware of cost differences. Some may not prefer to use a catheter that costs twice as much as another, while some physicians might prefer using the equipment that they were trained on and are now reluctant to standardize. Academic hospitals often will want to use all of the newest devices and technologies. They usually prefer the latest in technology in order to assure complete training for their fellows, as well as to assure patients and referring physicians that they have the most advanced equipment. However, we must all walk a fine line between having the latest and greatest equipment versus controlling costs. Don’t hesitate to initiate cost discussions with your physicians. Because device costs are tied to volume, administrators are often responsible for making volume guarantees to vendors and keeping track of their commitments. To get the big picture, review actual costs compared with reimbursements. We must each have a strategy for working with physicians, the purchasing department, and vendors. You may want to meet with the physicians and review costs per case in detail, asking why there were variations and how the variations might be reduced. Administrators should also check to make sure that all hospitals in their system are paying the same amount for a certain device. Summary Most of the everyday challenges facing EP lab administrators can be handled through improved communication and education. Communicating with physicians, coders and payers as well as among the members of the team will help to avoid many of the problems that are frequently encountered. Education is key for all involved as we face the ongoing challenges of improving efficiency while balancing costs with revenue and service to our patients.