Health Information Management

Tackle coding challenges by engaging physicians, seeking external feedback

JustCoding News: Outpatient, March 24, 2010

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Despite increased scrutiny from CMS and private payers, many provider organizations continue to make costly mistakes in coding, documentation, and often in both.

There’s no shortage of educational resources, of course. So what’s the problem? Three experts with extensive consulting experience share what they’ve seen and offer some advice.

Be motivated
It’s not as though the significance of proper coding is a mystery. Rather, says Jeannie Cagle, RN, BSN, CPC, manager at The Coker Group in Alpharetta, GA, it’s more like flossing and mammograms. “We all know that we should, but we don’t get around to it,” she says.

So what motivates her clients? First, the potential consequences of errors are severe. “I spend a lot of time defending physicians that have gotten into trouble with Medicare,” says Cagle. It’s costly. She also points to the possibility that providers may find more money. In an era of declining reimbursements, providers tend to undercode. Practices are “leaving money on the table,” she says.

Know what you don’t know
Maggie M. Mac, CPC, CEMC, CHC, CMM, ICCE,
director of network compliance operations at Mount Sinai Hospital in New York City, says the problem isn’t that practices aren’t generally diligent and thorough; they simply don’t know what they don’t know.

An administrator or certified coder may understand documentation requirements but lack the clinical background to comprehend the clinical nuances. Physicians, with the clinical background, often don’t grasp the finer points of documentation capture, Mac explains.

“There are so many pieces of the puzzle,” she says. Accurate documentation and coding requires more than understanding the individual pieces; you have to know how all of it comes together.

Physicians often like to blame the coders, says Adel Miles, CPC, senior consultant in the Salisbury, NC, office of Health Management Resources, Inc. If they complain to her, she reminds them: “They can only code what they read. Are you documenting everything you do?”

Some organizations have cut back on employee education, notes Mac. So the problem becomes one of not knowing what the organization is missing. Office managers typically aren’t coders; they don’t recognize the importance of coding compliance, and end up hiring unqualified people to handle it.

Some provider organizations don’t even invest in the resources to code correctly. Cagle comes across many practices that don’t have proper documentation. CPT books are out of date and they aren’t aware of the resources their specialty organization and CMS provide. “You don’t accidentally code correctly,” she says. “Winging it perpetuates the ignorance.”

Office managers need to take a more active role in making sure they either get the education they need or hire someone who has it. “They have to take it seriously,” says Mac. They determine how much priority a practice places on hiring and training the right people—and physicians are taking their cue from them, she said.

Make a difference on a budget
Not enough practices have people in place who recognize both the pieces and the puzzle, and hiring an outside consultant can be pricey. Mac offers a couple of tips for dealing with coding compliance on a tight budget:

  • Consolidate resources. Several practices can share a qualified internal review expert.
  • Annual checkups. Although your internal staff members will do the bulk of the work, hire a consultant or expert to validate it. You can find one through your healthcare attorney to come in at least once per year to assess your compliance efforts, provide compliance initiatives, and give you feedback and advice.

Don’t make it an afterthought, says Cagle. Too often, the person who manages coding compliance also makes the deposits, handles denials, and “does 15 other chores.” Chart audits are like playing the piano, says Cagle—If you do it only sporadically, it’s difficult to do it well.

Educate in small doses
When Miles goes into a practice to perform a coding audit, she also goes in to educate. It can be challenging to keep the practice motivated. “It’s like going on a diet,” she says. They stick to the plan for a few days, then “creep back to old habits.”

Miles recommends taking it slowly, especially when training physicians. Educate physicians frequently and in small doses so they “get it,” she says.

She walks physicians through various scenarios and asks them to think about the nuances of a particular encounter. Among the questions she may ask are:

  • What is the level of service?
  • What is the intent of the visit?
  • When there’s a hospital admission, who’s doing the admitting?

It’s not a matter of filling in the blanks; it’s a process of asking and answering the right questions.

Cagle, too, makes a case for framing chart audits as an educational activity. Physicians, in particular, are much more receptive when she takes that approach. “I want to be a friendly, educating auditor,” she explains. Her advice: Praise them for what they do right and give them the tools to do the rest better.

Shadow physicians
Having a coding expert shadow physicians can be an excellent educational tool. It allows the person handling compliance to see firsthand what the physicians are doing. Patients are usually amenable. The approach can be time-consuming, but it’s worthwhile because it incorporates a compliance check with education and immediate feedback.

With permission of both patient and physician, Miles will shadow a physician during a typical appointment. She writes down what she sees and hears and, when the visit is over, she’ll meet with the physician.

Miles often starts by asking what the physician thinks the level of service should be. Physicians frequently fail to fully document the history of present illness (i.e., HPI) despite asking probing questions.
Miles then uses a spot audit to see whether the physician got the message. She’ll attend an encounter and, if the physician documented the visit at the time of service, she audits the chart immediately with the physician standing there.

Look for patterns
In addition to looking at individual charts and physicians, take a snapshot of the practice.

As part of an evaluation and management (E/M) coding audit, you should run a utilization pattern for each physician, says Cagle. You can then compare the physicians within the practice.

“At a glance, you can see they are not billing like each other,” she says. If you assume they have the same patient demographics, the pattern should look the same.

So even without looking at the specifics, you can identify potential problems. That’s something a random chart review won’t reveal, says Cagle.

It becomes easy to identify wrong codes and other oddities, such as the “one-code Willies” who use the same handful of codes all the time. Cagle tells of one practice that, at checkout, used one of two codes for all visits: They reported code 99204 for each new patient and code 99214 for each follow-up. “I can tell you that’s not correct. Why they haven’t gotten in trouble already, I can’t say. But they will,” she says.

You can also compare to typical coding. CMS offers an example of a typical bell curve for E/M codes 99211–99215, Cagle says. A practice or physician with dramatically different utilization patterns is a prime target for CMS or private payer scrutiny.

Balance the consultant relationship
Ideally, a practice should have internal systems and routines to monitor compliance and educate physicians. A consultant can augment that process, serve as a resource, and conduct an occasional review to make sure everything is on target.

Not all providers will document exactly the same way, and it is important to review findings individually with each physician or nonphysician provider, says Mac.

Practices that take this approach must ensure that internal coding staff members and consultants present a united front for coding, says Cagle.

The rationale is two-fold: It’s important to present a consistent message, of course, but internal staff must also have the physicians’ respect. It can be a difficult dynamic when the internal staff member has to tell physicians they are doing something wrong. A consultant shouldn’t do anything to exacerbate that situation, Cagle says.

In-house experts may have more difficulty telling physicians they aren’t doing well, agrees Miles. Not everybody has the ability to address physicians with “finesse and authority,” she says.

The providers need quality feedback, not just “you coded this as a level five and it should have been a level three,” Mac says. “They will learn nothing from that approach and feel like they are being scolded.”

Feedback needs to be meaningful and educational without threatening. “Be firm but flexible in offering to provide tools such as laminated cards of the documentation components for quick reference,” Mac says.

The internal person must be able to hold his or her ground with the physician, adds Miles.

Expect physicians to step up
Educate staff members so they can support the physicians—not replace them, Miles says. Part of the physician’s job is to document services performed and identify appropriate CPT and ICD-9 codes. The only staff members who should be assigning codes are the coders, and they should only make changes based on documentation.

Unfortunately, many practices do not work that way. At checkout, a staff member may enter a nondescript ICD-9 code.

“When ICD-10 [takes effect], it’s going to impact revenue if they don’t learn to be more specific,” Miles says.

Physicians may also be guilty of choosing a generic or even out-of-date code, which isn’t surprising, Miles says. Look at the back of many encounter forms currently in use. The organization may not have updated the codes for years.

Miles recommends that her clients delete diagnosis codes from encounter forms. She encourages them to use other tools, such as the AMA’s laminated sheets of common diagnosis codes. “It makes them more cognizant of a wider variety of choices,” and it encourages them to be more specific, she explains.

She offers another tip: When a patient has blood work, the physician needs to link the CPT code for the procedure with the diagnosis code. “Don’t leave it to the staff,” she says. If he or she doesn’t know why the physician is ordering a lab, a staff member have to guess, and will probably guess wrong. “That’s why so many labs are denied and why labs don’t meet medical necessity.” It’s not that they aren’t medically necessary; it’s that the practice failed to provide the proper code.

This approach means more responsibility for the physician, but as Miles notes, the physician must sign off on everything and is ultimately responsible for any errors.

Ignore the folklore
If there’s a bigger problem than insufficient knowledge about coding and documentation, it’s a surfeit of bad “facts.” When Cagle comes across clients with inaccurate information, she asks where they learned it. Almost always, it came from a casual conversation: “So and so told me . . .”

That’s not going to hold up to any scrutiny. “Look at written resources,” Cagle says. “That’s your only defense in the case of an audit.”

Editor’s note: This story was originally published in the March issue of Managed Care Contracting & Reimbursement Advisor. E-mail your questions to Editor Roxanna Guilford-Blake at

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