AFC Urgent Care in Memphis, Tennessee, is affiliated with a national franchise, but independently owned and operated. Like most urgent care practices, the clinic has a small staff of two full-time physicians, one part-time physician, and a small auxiliary of medical assistants, X-ray technicians and office staff.

THE PROBLEM

Like many small urgent care clinics and other medical practices, at the onset of the COVID-19 pandemic, AFC's patient volume went down as much as 75%.

"The pandemic itself was stressful, but it was compounded by concerns about our finances," said Dr. Alice McKee, family medicine physician and medical director at AFC Urgent Care. "As a small, independently owned clinic, we were bracing for lost revenue caused by the pandemic. We did not have the financial resources of a larger organization to carry us through, and therefore we worried we would become insolvent.

"Given that we couldn't change our patient volume issues caused by the pandemic, the most immediate action we could take was to look at how we could improve our coding and billing functions, as well as collections," she continued. "We analyzed and evaluated everything – staff, processes and technology."

In addition, in September 2020, the American Medical Association released the 2021 Current Procedural Terminology code set – the first major revision of the CPT code in more than 25 years. The revisions greatly affected outpatient evaluation and management (E/M) services, a major business driver for urgent care clinics.

According to the AMA, the new E/M coding and documentation guidelines were intended to provide AFC Urgent Care with a more simple and flexible process. However, the timing couldn't have been worse for the clinic. Suddenly it was billing for more lower-level visits despite delivering the same quality care to patients.

"We wanted to be sure we were realizing income for every dollar earned as much as possible," McKee explained. "Not just during this time but into our future as well."

PROPOSAL

Health IT vendor ExdionRCM proposed implementing a technology that would allow AFC Urgent Care to revisit encounters and identify and process issues for correction. It also included features such as intuitive coding to help staff code more accurately.

"While we wanted to go back and scrub our encounters, we also wanted a way forward," McKee said. "While most billing scrubber software can only identify billing errors, the vendor's ExdionACE artificial intelligence focuses on the relationship between the International Classification of Diseases and the Current Procedural Terminology codes.

"The solution is packaged into three applications: an Auto Coding module for high coding accuracy, a Revenue Integrity module that leverages code relationship algorithms, and a Computer-Aided Provider Documentation module that drives CDI by recognizing E/M levels, medical decision-making and missing documentation."

The vendor explained that ExdionACE would easily integrate with the clinic's EHR and practice management systems using APIs, which was a relief to McKee. It pulls encounter reports from any system – staff are not required to manually pull, upload and submit them. It can pull as many encounters as needed. Everything is automated.

"At the heart of our problems was coding," McKee noted. "An important feature that stood out to us is that the technology does not only scrub after coding. Instead, the coding function is intuitive and proactive, and it would be customized for us.

"With this automated system, the solution would proactively provide codes, including missed billable codes, and not make us guess which codes were correct," she continued. "Importantly, it provides codes based on our clinic's diagnosis and standard of care, instead of a primarily rule-based system with little to no data learning processes."

Finally, the clinic's investment in this technology is based upon a reasonable percentage of revenue recovered, not a large, up-front capital investment, and it's capped at a fair amount, she added. This means the implementation, analysis and results are done carefully and precisely – the vendor and the clinic both have a mutual interest in an optimal outcome.

MEETING THE CHALLENGE

ExdionRCM's technology integrates with AFC Urgent Care's Experity/DocuTap EHR and PM system. The vendor set everything up.

"Everyone on our team uses the solution every day," McKee said. "ExdionACE automatically scans a huge volume of charts and encounters in minutes. The technology processes and flags possible documentation gaps, and identifies under-billed and over-billed services, or even services that are not billed, thereby uncovering potential revenue opportunities.

"After implementation of the technology was complete, the solution scrubbed our files," she continued. "The solution extracts data from the EHR and practice management system using an AI tool to parse through every clinic encounter – which numbered in the thousands – to identify potential compliance and revenue gaps."

If a gap is found, the physician or appropriate person is notified by email to review the documentation and provide possible missing information or clarify for appropriate coding.

"The technology helps to educate our team not only on the new E/M documentation guidelines but also on the use of outdated codes that would lead to rejections, missing modifiers and other coding errors," she explained. "As the saying goes, old habits die hard. We realized we were still documenting and coding E/M services the way we did it before the new codes came out.

"Also, some doctors were inadvertently missing documentation of rendered services, oftentimes due to being busy or distracted by some other event," she added.

It became clear the clinic was not coding for all services. It needed to rethink its process, because it was a significant cause of lost revenue. This meant changing the mindset and doing a better job of documenting patient visits.

"Interactions such as patient discussions, decision-making processes, medical record reviews, discussions with people other than the patient – all these things accurately reflect the elevated level of many visits and, consequently, the higher level of reimbursement earned," McKee said.

"We now receive daily reports that help us improve the way we document and code patient encounters," she continued. "Before, there was no real process for what happens from charting to billing, but now we have a solid, effective process."

RESULTS

AFC Urgent Care now is doing a better job with its charting and coding. As a result, it's no longer missing payments for many of the services it renders. This is boosting revenue by about 25%. The underlying reason for loss of revenue was suboptimal coding. Considering the clinic sees about 30 patients daily, errors can add up to a considerable sum.

"A very detailed reporting system gives a five-mile-high view, but it also provides the granular details that enable us to see encounter information, improve processes and understand exactly where we recovered revenue," McKee noted. "For each doctor, we can look at E/M code breakdown from Level 1 to Level 5.

"We can see how many patients are seen by a doctor, input fees, flagged fees and percentage of revenue flagged," she continued. "Furthermore, we can see the exact reason something got flagged, whether it is due to missing documentation, missing diagnosis information, or missing codes for treatments or reports."

All this data can be filtered by doctor, timeframes, encounters and more. The staff can also see data showing average dollar value of charges billed, allowed amounts and payments received.

McKee reported some more of the clinic's achievements with the technology:

• To give perspective for early adoption, in December 2020, the clinic audited 937 patient encounters, of which 914 had suboptimal coding issues. That's 97.5% of total visits with a coding issue and lost revenue. Staff members found out they were using lower-level intensity E/M codes more often than they should, and modifiers weren't used optimally based on coding guidelines. As a result of suboptimal coding, the clinic lost $44,000 that December – that's about 25% of total monthly revenue.
• Fast forward to March 2022, the monthly audit of insured patient encounters led to an increase in revenue of 30% by correcting flagged encounters, including missed modifiers and administration codes, which was higher than more recent months. Looking back at the previous 12 months to March 2021, recovered revenue percentages totaled 18%.

ADVICE FOR OTHERS

"First, don't be afraid of this technology and put off looking into it," McKee advised. "I'll be the first to say that I'd rather focus on patients than back-office technology. But taking the time and making this a priority will greatly benefit your practice's financial and overall well-being.

"It's not difficult to onboard and use. It recovers revenue that you earned, and it makes your daily life much easier," she added. "Eventually, you will be relieved."

The other point McKee makes is that using revenue integrity technology does not require a massive, disruptive overhaul of business operations. It plugs into an EHR and practice management platform and does not replace anything, she said. No one wants to start all over, she added, and with this technology, no one has to.

"As the old saying goes, 'Don't nickel and dime yourself to death,'" she said. "That's what we were doing to ourselves. Losing even small amounts of money for each patient encounter really adds up. If even one procedure is routinely not charted, coded and billed properly – even something as simple as administering an injection – it really adds up."

Embrace daily audits, she also advised. Use the technology every day to find and correct issues. Team members will gradually improve, and errors will diminish. But still, one should have a process of checks and double-checks every day.

"Finally, when you are selecting a vendor, ask questions," she said. "How will the proposed solutions align with your business goals? How will they figure the return on investment? ROI should be determined by considering the Medicare fee schedule, as well as the charges allowed and payments received, to quantify your top-line improvement.

"This assessment should not be left for you to do," she concluded. "You should be given reports that show exactly how the solution is improving your clinic in every way – process, efficiency and revenue. The solution should easily pay for itself."

Twitter: @SiwickiHealthIT
Email the writer: bsiwicki@himss.org
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