Revenue Cycle Management

Background

The changes to the Electronic Transactions and Code Sets Rule raise serious challenges regarding Revenue Cycle Management (RCM) practices among healthcare providers. The current modification to the Rule, which introduces the implementation of 5010 and ICD-10, requires sweeping changes and requires providers to rethink how they handle RCM. In order to strengthen RCM practices, providers will need to:

These requirements constitute a very different level of RCM than many providers have or vendors are currently capable of delivering.

Traditional Revenue Cycle Management

The current coding sets and RCM processes make little use of clinical documentation and rely on often oversimplified and outdated diagnosis and procedure coding. The level of coding expertise for small hospitals and physician practices is normally considered average at best.

RCM

Clinical Revenue Cycle ManagementSM (CRCM) for Maximizing Outcomes, Pay-for-Performance, and Value-Based Purchasing

The level of detail available in ICD-10-CM and ICD-10-PCS places an entirely new emphasis on the capture of clinical documentation and requires the use of an EMR. The CRCM model looks very different by adding process steps for documentation and outcomes-based payment, including pay-for-performance and value-based purchasing from third-party payers.

Changes in Clinical Documentation

The modifications required in clinical documentation represent perhaps the greatest challenge in changing behavior, particularly on the part of physicians who normally do not like to document and who often delegate coding responsibility to support staff. The level of detail required by ICD-10 makes it difficult, if not impossible, to determine the correct coding after the fact.