Case Study: How Netrevmed’s Coding Excellence Transformed a Pediatric Practice

Introduction

The Pediatric Practice, a mid-sized medical clinic in the Midwest, struggled with high claim denials, delayed reimbursements, and inefficiencies in medical records management. These challenges threatened the practice’s financial stability and operational efficiency. Partnering with Netrevmed, a leading medical billing company, the Practice implemented a highly effective coding process that slashed denials, streamlined workflows, and enhanced medical records management. This case study details how Netrevmed achieved coding excellence, the specific steps they took, and the resulting benefits, including faster collections, improved compliance, and operational scalability.

Background: The Challenges at a Pediatric Practice

Before collaborating with Netrevmed, the Practice faced significant revenue cycle management (RCM) issues:

• High Denial Rates: Around 25% of claims were denied due to coding errors, incomplete documentation, or payer policy non-compliance.
• Delayed Collections: Payments took an average of 60 days, impacting cash flow and growth opportunities.
• Inefficient Workflows: Manual coding and lack of standardization caused delays in claim submission and follow-up.
• Poor Medical Records Management: Inaccurate or incomplete records increased denial risks and audit vulnerabilities.
• Staff Burnout: Overworked billing staff struggled with errors and inefficiencies, leading to high turnover.

These issues strained finances and patient satisfaction, as billing disputes arose from administrative delays. The Practice needed a partner to overhaul its RCM, and Netrevmed stepped in with a focus on coding excellence.

The Solution: Achieving Coding Excellence with Netrevmed

Netrevmed conducted an in-depth analysis of the Practice’s RCM processes, pinpointing coding as the critical area for improvement. Their approach to achieving coding excellence involved a combination of rigorous audits, standardized protocols, cutting-edge technology, comprehensive training, and proactive denial management. Below are the specific steps Netrevmed took to ensure coding accuracy and efficiency:

1. In-Depth Coding Audits and Benchmarking

Netrevmed initiated the process with a comprehensive audit of the Practice’s claims history, analyzing 12 months of data to identify denial patterns. They found that 45% of denials stemmed from coding errors, such as incorrect Current Procedural Terminology (CPT) codes, missing International Classification of Diseases (ICD-10) codes, or insufficient documentation specificity. To establish a baseline, Netrevmed benchmarked the Practice’s coding accuracy against industry standards, revealing a 20% gap in compliance with American Medical Association (AMA) guidelines.

To maintain excellence, Netrevmed implemented monthly coding audits, where certified professional coders (CPCs) reviewed 10% of claims. These audits included detailed feedback reports for providers, highlighting errors and recommending corrections. This iterative process ensured continuous improvement and reduced error rates over time.

2. Development of Tailored Coding Protocols

Netrevmed created customized coding protocols tailored to the Practice’s workflow. These protocols were designed to align with AMA, Centers for Medicare & Medicaid Services (CMS), and payer-specific guidelines. Key elements included:

• Specialty-Specific Code Sets: Detailed guides for selecting CPT and ICD-10 codes based on common procedures and diagnoses for each specialty.
• Documentation Templates: Standardized templates for clinical notes to capture all required details, such as medical necessity and procedure complexity.
• Payer Policy Checklists: Pre-submission checklists to ensure claims met individual payer requirements, reducing rejections.

These protocols were embedded into the Practice’s workflow, ensuring coders and providers followed a consistent, compliant process. Netrevmed also conducted quarterly reviews to update protocols based on regulatory changes or new payer policies.

3. Deployment of AI-Powered Coding Technology

Netrevmed integrated an advanced electronic health record (EHR)-compatible coding platform with artificial intelligence (AI) capabilities. The platform analyzed provider notes in real-time, suggesting accurate CPT and ICD-10 codes while flagging potential errors, such as unbundling or mismatched diagnoses. Key features included:

• Automated Code Suggestions: Reduced manual coding time by 35% by pre-populating codes based on clinical documentation.
• Payer Rule Integration: Cross-referenced codes with payer policies to ensure compliance before submission.
• Documentation Alerts: Notified providers of incomplete or vague notes, prompting immediate corrections.

The platform also centralized medical records, enabling seamless access for coders, providers, and billing staff. This eliminated paper-based records, reduced documentation errors by 25%, and ensured audit-ready records management.

4. Intensive Training and Certification Programs

Netrevmed recognized that human expertise was critical to coding excellence. They launched a robust training program for the Practice’s providers, coders, and billing staff, focusing on:

• Clinical Documentation Improvement (CDI): Training providers to document encounters with sufficient detail to support accurate coding.
• Code Updates: Regular sessions on ICD-10 and CPT code changes, including annual updates and specialty-specific nuances.
• Error Prevention: Workshops on avoiding common mistakes, such as upcoding, undercoding, or omitting modifiers.

Netrevmed also required all coders to maintain CPC certification and provided sponsorship for staff to attend advanced coding courses. Bi-monthly webinars kept the team informed of industry trends, fostering a culture of continuous learning. This training reduced coding errors by 30% within three months.

5. Proactive Denial Management and Analytics

Netrevmed established a dedicated denial management team to handle rejected claims swiftly. The team used data analytics to track denial reasons, categorize them (e.g., coding errors, documentation issues), and prioritize appeals. They developed a denial dashboard for the Practice, providing real-time insights into denial trends and resolution rates.

When a major payer rejected claims for a specific CPT code, Netrevmed’s team identified the issue (a new policy requiring additional modifiers) and updated the coding protocols within 48 hours. This proactive approach recovered 90% of initially denied claims, boosting revenue.

6. Collaborative Feedback Loops

To sustain coding excellence, Netrevmed instituted regular feedback loops between coders, providers, and the billing team. Monthly meetings reviewed audit findings, denial trends, and coder performance, fostering collaboration. Providers received personalized reports on documentation gaps, enabling targeted improvements. This collaborative approach ensured alignment across teams and reinforced accountability.

Results: Transformative Outcomes for the Practice

Within six months, Netrevmed’s coding excellence transformed the Practice’s RCM. Key outcomes included:

Additional Benefits of Netrevmed’s Coding Process

Netrevmed’s approach delivered long-term advantages:

• Regulatory Compliance: Accurate coding minimized audit risks and ensured adherence to CMS and payer regulations.
• Patient Satisfaction: Clear, error-free billing reduced disputes, improving patient trust and loyalty.
• Actionable Insights: Analytics provided data on service trends and payer behaviors, informing strategic decisions.
• Scalability: Efficient processes supported higher patient volumes without additional administrative costs.
• Staff Retention: Reduced workload and robust training improved morale and lowered turnover.

Conclusion

Netrevmed’s partnership with the Practice showcases the power of coding excellence in transforming medical billing. Through meticulous audits, tailored protocols, AI-driven technology, intensive training, proactive denial management, and collaborative feedback, Netrevmed reduced denials, accelerated collections, and streamlined operations. The additional benefits of compliance, patient satisfaction, and scalability highlight the value of a robust coding process. For practices facing RCM challenges, Netrevmed’s approach offers a proven model for financial and operational success.