The Physician’s Role in Coding - doctorsdigest.net

1 Chapter in Brief:Chapter in Brief: Doctors are ideally positioned to accurately capture informa-tion from office and hospital visits, not only for documentationpurposes, but also for billing. Although documentation is the basis for Coding , doctors do notalways include enough detail to support accurate codes. Modifiers 25 and 59 are used to signal payers that multipleservices or procedures were provided to a patient on the sameday and that these meet criteria for separate payment. Withoutthese modifiers, the charges may be denied. After taking a basic course on Coding , doctors and their staffshould continually attend seminars to refresh themselves on therules and regulations, which are subject to physicians would be happy to delegate all Coding issues to thestaff, but doctors play an integral role in the Coding BILLING AND CODINGThe physician s Role inCodingMost doctors view Coding as a necessary evil, saysPatricia Hubbard, CPC, CPC-OBGYN, a medical prac-tice manager in New York State.

2 Most would rathertake care of their patients and work on what they were trained todo. Instead, they may also be responsible for choosing proce-dure and diagnostic codes, which may involve lengthy or com-plicated are the ones who actually go through the medicaldecision-making process; thus they are ideally positioned tomore accurately capture information from office and hospitalDDPCP_030409F:DDPCP_09_10_QXPv6 3/12/09 9:46 AM Page 38 DDPCP_030409F:DDPCP_09_10_QXPv6 3/11/09 1:56 PM Page 39 DDPCP_030409F:DDPCP_09_10_QXPv6 3/11/09 1:56 PM Page 40 DDPCP_030409F:DDPCP_09_10_QXPv6 3/11/09 1:56 PM Page 41visits, not only for documentation purposes, but also for billing. They re the only ones who truly know what s going on intheir minds when it comes to picking management options anddifferential diagnoses, says Marie Felger, CPC, CCS-P, an Indi-ana-based Coding instructor and medical office auditor. Astaffer can look at the exam and count the necessary elements,but the physician has a true handle on the medical the physician should select the evaluation and man-agement code.

3 Even when doctors don t do procedural Coding , it is importantfor them to be familiar with the CPT descriptions and guidelinesfor the procedure codes pertaining to their specialty. If [doctorsare] familiar with what the code describes, they can make suretheir operative note is specific enough, says Nancy Enos,FACMPE, CPC, CPC-I, CPC-E/M, a consultant and codinginstructor in Warwick, Historically, doctors haven t paid a whole lot of attention toACCURATE BILLING AND when physicians take an active role in Coding , it doesn t eliminatethe need for credentialed coders. Certified coders are trained to under-stand the complex criteria for proper code selection, the appropriate useof modifiers, CCI edits, and bundling issues. According to Deborah Grider,CPC, president of the National Advisory Board of AAPC (American Academyof Professional Coders), a certified coder can be their partner and cancorrect Coding before it goes to the insurance company. It can keep themfrom losing revenue.

4 Physicians do not need or desire to be coders, says Garry L. Huff, MD,CCS, associate director of DRG Review, Inc. They need to have confidenceand rely on the Coding and documentation professionals. But for these pro-fessionals to be able to do their jobs, they need to have open lines of com-munications with their physicians. Coders also play an importance role in compliance. They make sure thatcharges without proper documentation don t get sent, says Rita Bowen,MA, RHIA, CHPS, SSGB, enterprise director, HIM Services for ErlangerHealth System in Chattanooga, Tenn. They are our eyes and ears for com-pliance before the claim goes out the door, says Ms. Bowen. They retrained to ask questions if they see a charge for something that has notbeen documented. Hire Credentialed Coders DDPCP_030409F:DDPCP_09_10_QXPv6 3/11/09 1:56 PM Page 42codes, admits Gerald J. Russo, MD, FAAP, chief medical offi-cer of Bloodhound Technologies, a claims editing companybased in North Carolina.

5 Doctors didn t spend much time ondiagnosis codes because the procedure (CPT) codes drove therevenue. Because of this, they wouldn t differentiate betweenan allergic asthmatic and an intrinsic asthmatic; they would justuse the general code for asthma. But that was before Coding wasused to track quality of Russo, who practiced pediatrics for 10 years beforebecoming Bloodhound s chief medical officer, says that at theminimum, doctors should do their own code assignment for theevaluation and management service. Looking from the outside,it s easy to misjudge the complexity of the service, he says. Inthe best functioning office, the doctor assigns the code on a rout-ing slip. And the doctor has the Coding and billing specialist lookat it to see if there are any questions about over-assigning orunder-assigning and [has the specialist] get back to him or herto address any concerns. Superior SuperbillsTo make it easier for doctors to do their own Coding , the officeshould print commonly used codes for that specialty on thesuperbill.

6 The doctor can then check off items on the chargesheet so that it s ready for billing. While this procedure seemsobvious, not all office practices follow it. The American Acad-emy of Professional Coders (AAPC) estimates that only 50 per-cent of physicians use Sword, CCBS, who established her own medicalbilling service in Illinois after working in medical offices, saysthat one of the first things she creates for a new client is thesuperbill, if the office doesn t already have one. We design thesuperbill so all you have to do is circle, circle, circle, she this system, she usually gets the information she needs tofile accurate physicians can t rely on the superbill alone to ensureproper Coding . Ms. Felger says doctors need to be certain thatstaff members are capturing all ancillary charges, like physicians themselves need to be familiar with documenta-tion guidelines in order to select the correct level of evaluationTHE physician S ROLE IN :DDPCP_09_10_QXPv6 3/11/09 1:56 PM Page 43and management code for the visit.

7 They can t just turn it allover to someone else, she Coding rules should physicians know? They need tounderstand that coders can t specify a diagnosis to a higher levelthan the doctor has [documented in his notes], says Garry , MD, CCS, associate director of DRG Review, Inc., anational consulting firm that works with hospitals to link theclinical and Coding processes. For example, Dr. Huff says thatonly the doctor can provide the specification as to the patient stype of anemia. In the office you must link every procedure you do with acovered diagnosis, Dr. Huff says. If you do an EKG and youput down something like abdominal pain, very likely you won tget paid, because they recognize that you do not do an EKG forabdominal pain. You must link a diagnosis with a CPT code. Dr. Huff sometimes gives a lecture titled Coding and Physi-cian Self-defense, which highlights why physicians need to payclose attention to the Coding of their records and ways to bettercommunicate with those responsible for Good documentation is what produces good Coding , saysMs.

8 Hubbard. It s important for physicians to be thorough inthe documentation of the patient s history, the physical exami-nation, and the medical decision making. Documentation serves many purposes; the most obvious is ahistorical record of the patient s condition and treatment is the basis for Coding . But doctors do notalways include enough documentation to support their codes,especially with E/M codes. They don t document enough forthat level of service. They miss things in the history that theyACCURATE BILLING AND Good documentationis what produces good Coding , says Ms. Hubbard. It s important for physicians to be thorough in the documentation of thepatient s history, the physical examination, and the medical decision making. DDPCP_030409F:DDPCP_09_10_QXPv6 3/11/09 1:56 PM Page 44 THE physician S ROLE IN but didn t document, says Deborah Grider, CPC,CPC-H, CPC-P, CCS-P, CCP, a consultant and president of theNational Advisory Board of the American Academy of Profes-sional Coders (AAPC).

9 Ms. Enos notes that doctors should make sure their medicalrecord meets two requirements: Is it complete and did I provethe treatment was necessary?Even when doctors do a good job documenting the physicalexam, they sometimes fail in documenting the history. Ms. Fel-ger says the area that physicians have the most trouble docu-menting is history of present illness. If patients have amultitude of problems, they ll likely need the highest level ofservice and should code for that, Ms. Felger says. If [doctors]haven t documented the history of present illness well enough,it s going to limit [patients] to a lower level of service. She gives an example of abdominal pain as the chief com-plaint. That s one element of the HPI, but that s not enough toget to a higher level. They have to say something like lowerabdominal pain, moderate severity, going on for two days, andit s constant. Those are enough elements to get to that higherlevel. If the rest of the exam points them to a 99214 or higher,they ll be able to bill it, Ms.

10 Felger Hubbard gives the example of a hysterectomy, a proce-dure that may normally take 90 minutes. If the patient has exten-sive pelvic adhesions, it may take the physician more than twohours. She says that if the physician carefully documents thisextra time and work, the coder can account for this in the claim,ethically asking the payer for additional money. Otherwise, thecoder doesn t have the information needed; and the physicianloses money, she October 2006 the medical severity DRG, or MSDRG, wasinstituted. The system is similar to the ICD-9 system, says Doctors and hospitals have to accurately document theNeed practice solutions fast?Click on the Instant Issue Accessbutton in the upperright hand corner on our homepage or use our new KeywordSearch at :DDPCP_09_10_QXPv6 3/11/09 1:57 PM Page 45conditions they re treating so the correct ICD-9 and MSDRG codes are assigned. He notes that with the old system, conges-tive heart failure would be a reimbursable diagnosis. The newsystem requires documentation to include left- or right-sided,systolic or diastolic congestive heart failure.