Best Practice Submission
Tripler Army Medical Center’s “New” Patient Process through Correct Coding of
New Patients as New Patients
Points of Contact: Ms. Seanna Carter, (703) 694-3247,
Seanna.M.Carter.civ@mail.mil
Tripler Army Medical Center Resource Management Division, Internal Medicine, Family
Medicine, and Patient Administration Division, and the AHLTA MAPs Team
Submitted by MAJ Robert K. Fredregill
2 February 2013
Executive Summary: Tripler Army Medical Center (TAMC) lost approximately $1.15
million in 2012 by erroneously coding new patients as established during primary care
encounters. TAMC initiated the “New” Patient Process January 2012, resulting in a
95.64% decrease in lost revenues from Internal Medicine and a 60.49% decrease in
from Family Medicine.
Objective of the Best Practice: The “New” Patient Process was designed to identify
new patients and correctly document encounters resulting in maximized revenues from
primary care visits. The process aims to prevent the loss of earned revenues due to
incorrect coding of new patients encounters as existing patient encounters. Tripler
Army Medical Center (TAMC) and the AMEDD continually fail to maximize
reimbursements from earned encounters resulting in reduced revenues and budgetary
shortfalls in this current environment of economic constraints.
Background: In September 2012, the Patient Administration Systems and Biostatistics
Activity (PASBA) Established Patient E&M Code Utilization metric (EMCU) reported that
the AMEDD lost $20 million (rolling average) due to coding new patients as existing
patients. TAMC lost $1.15 million in revenues. TAMC leadership initiated the “New”
Patient Process to stem the hemorrhaging of earned revenues in the outpatient clinics.
Internal Medicine and Family Medicine initiated the process in January 2012. In
January, Internal Medicine and Family Medicine lost approximately $7,000 while
averaging a loss of over $8,900 per month for the preceding year.
Literature Review: No articles referencing percent error of coding new patients as
established patients were discovered. Articles referencing coding errors demonstrated
a strong tendency for providers to incorrectly code encounters with increased frequency
for new patients (Kikano, 2000). Providers tended to over code new patients and under
code existing patients (King, 2001). Under coding leads to decreased revenues while
over coding leads to excessive billing and increased national medical expenses. To
alleviate coding errors, it is recommended that physicians receive continuing coding
education regarding breadth and depth of patient encounters (Kikano, 2000).
Implementation Methods: The process involved a multi-pronged approach to resolve
the issue of incorrect coding. The Resource Management Division (RMD) (Ms. Carter),
Patient Administration Division (PAD), AHLTA MAPs training team, and clinic leadership
initiated a program of staff, clinician and support, education and process improvement
to maximize new patient identification and encounter coding. A functional team of RMD
and PAD coders worked with the clinic’s support staff. A team consisting of RMD, PAD
coders, and AHLTA MAPs team member worked with physicians to ensure regulatory
requirements regarding coding were understood and demonstrated correct coding
practice within AHLTA. Both teams provided education and hands on training to
properly identify and code the encounter. Additionally, a process was created to
facilitate and incorporate new patient identification and physician notification. A CHCS
adhoc was modified to reflect the TAMC environment. The adhoc was transferred from
Winn Army Medical Center. The adhoc was used to identify next day patient
appointments that are new to the clinic. The adhoc is a tool designed to supplement the
front desk staff query of the patient regarding their status in the clinic. The teams
created hand outs and power point presentations for physical and visual aids. Data was
collected and plans for facility wide implementation were planned for April 2012.
Results: The Family Medicine (FMC) and Internal Medicine (IMC) lost an average of
$8,900 a month for the year of 2011 for a combined total of $213,000. The clinics
ranged from $6,000 to $12,000 any given month. The “New” Patient Process was
started in January 2012 and resulted in a decrease in the average monthly loss and the
total loss in clinic revenues. The monthly average loss for the clinics was $4,000 over 9
months. The months ranged from $400 to $7,100. Comparing December 2011 to
September 2012, the FMC produced a 60.49% decrease in lost revenues from $6,932
to $2,739. The IMC produced a 95.64% decrease in lost revenues from $8,899 to $388.
Comparing the months of September 2011 to September 2012, the FMC produced a
77.11% decrease in lost revenues from $11,966 to $2,739. The IMC produced a
96.27% decrease in lost revenues from $10,413 to $388. A statistical review of the data
resulted in statistically significant change in lost revenues pre-process implementation.
A t-Test: Two-Sample Assuming Equal Variances, with an alpha of .05, was used to
evaluate for significance for FMC and IMC. The p value for FMC and IMC was less
than 0.001.
Conclusion: The “New” Patient Process was successful in reducing lost revenues due
to incorrect identification and coding of new patients as existing patients in AHLTA. The
delta for average monthly losses was $4,881 and the delta for total losses was $88,000.
These numbers are for two clinics, the FMC and the IMC. Successful facility wide
implementation and effective command presence will ensure significant decreases in
unnecessary lost revenues. The CHCS adhoc can be exported to all facilities in the
AMEDD but will require modification for each environment. Additionally, with the
change in MEPRs for PCMHs, additional modifications may be necessary.
Consideration for exportation across the AMEDD can significantly reduce the annual
loss of $21 million in revenues earned in outpatient clinics.
Figure 1.
TAMC IMC & FMC EMCU Lost Revenue
$0
Lost Revenues
$2,000
$4,000
$6,000
$8,000
Family Medicine Revenue
Intern Medicine Revenue
$10,000
"New" Patient Process Implemented
$12,000
References
Kikano, George E. (2000). Evaluation and management services. A comparison of
medical record documentation with actual billing in community family practice.
Journal: Archives of Family Medicine, 9 (1), 68-71.
King, Mitchell S.(2001). Accuracy of CPT Evaluation and Management Coding by
Family Physicians. Journal of the American Board of Family Practice, 14 (3),
184-192.