Data collection is an important aspect of the revenue cycle functions. Collection begins with the recording of patient demographic and insurance information at the point of registration. It then continues throughout the revenue cycle workflow with the capture of treatment information, charges, diagnostic and procedural codes, claims data, and information resulting from payments and denials. The data is housed in various databases, some that are standalone and others that are integrated. These databases can be accessed by authorized personnel to obtain the data needed in the performance of the healthcare facility’s planning, operations, and reporting requirements.
You work as a Coding Manager at a hospital. The hospital is considering building an Ambulatory Surgery facility for orthopedic and general surgery procedures, and several providers are interested in moving their practices and surgical interventions to this new location. In preparation for the Request for Proposal (RFP), the executive team is in need of clinical data. The HIM Director has been contacted and asked to pull statistical data.
At the HIM Director’s request, you have created a report of the top 5 diagnoses/procedures that shows total charges, total reimbursement, and quarterly patient volumes. In addition to the report, the HIM Director would like for you to analyze the data.
type your responses to the questions below:
- Which of the diagnoses/procedures would be the highest revenue generating?
- Which of the diagnoses/procedures may be considered for exclusion from the initiative based on volumes or revenue-and why?
- Which of the diagnoses/procedures has a high volume, but lowest revenue?
- Which of the diagnoses/procedures would benefit the most with a shift in payer mix (increase or decrease in patient volumes by payer)? Which payer and what type of change in volumes?
Note: Payer mix is the proportion of reimbursement that is generated from the different payers within a subset. In this example, there are 3 payers contributing to the total reimbursement for the 5 different subsets of procedures performed.
- Which of the diagnoses/procedures would benefit the most from increased patient volumes?