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Dealing with docs: Tips and tricks to ensure physician assistance with coding and documentation compliance

Radiology Administrator's Compliance and Reimbursement Insider, March 1, 2007

The perceived overuse of diagnostic imaging has become the focus of increased payer and government scrutiny. That makes raising physician awareness and assistance in submitting appropriate documentation more important than ever.

"Too often, doctors are so focused on patient care they sometimes forget to focus on coding and documentation. But if they do not, they won't get paid for the work they do," says Stacie L. Buck, RHIA, CCS-P, LHRM, RCC, vice president of Southeast Radiology Management in Stuart, FL.

Some physicians think documentation takes time away from patient care and that compliant coding reflects nothing about the quality of attention patients receive.

"These statements are just not true," says Stacy Gregory, RCC, CPC, president of Gregory Medical Consulting Services, in Tacoma, WA. "Good documentation is critically important to patient care."

Lessons for physician learning

Physicians typically have a limited understanding of the fiscal world in which they operate, according to Gregory.

For example, medical school teaches physicians how to scan the breast in search of potential lesions, but not about the difficulties of obtaining payment for the procedure.

Make educating physicians about documentation and coding a priority. Explain documentation guidelines according to both the American Medical Association's Current Procedural Terminology book and the American College of Radiology, she says.

Regardless of their profession, certain people show particular interests in specific subjects. Find one person who pays more attention to the documentation and foster a positive relationship with him or her.

Express your appreciation for his or her documentation skills and attention to detail. Then, encourage that person to share such knowledge with colleagues. Make this person your physician champion to assist in physician education. "Physicians are more likely to consider messages coming from another physician," says Buck.

Make sure to differentiate between the type of language physicians use and the type of language you, as an administrator, manager, or coder, use on a day-to-day basis. "Doctors don't understand code-speak," says Gregory. Clinical-speak and code-speak do not necessarily go hand-in-hand."

Recruit someone from your coding department as a physician liaison, as well. Put that person in charge of communicating with physicians, sharing local coverage determinations, and payer developments.

This liaison should explain to physicians how documentation helps coders distinguish between procedures, and how such distinctions sometimes reflect big dollar amounts, says Buck.

Tips for talking

You don't need to associate dealing with physicians with that awkward annual Thanksgiving conversation with your Aunt Edna. A few simple solutions can make physician/administrator exchanges effortless.

Pay attention to the first rule of thumb-don't be intimidated by physicians, says Buck. Be assertive, but not aggressive. Look them in the eye, remain calm, and behave appropriately, she says.

In addition, offer physicians an opportunity to speak privately about any documentation concerns you have.

Identify and address documentation errors right away, says Buck.

Timely discussions with physicians facilitate correct claims on the front end. They also instill a sense of urgency and importance. Frank conversations diffuse tension buildups and eliminate opportunities for additional errors.

Conversely, cornering a physician to discuss documentation when he or she happens to walk by establishes a confrontational atmosphere, says Gregory. By inviting physicians to cooperatively discuss claims concerns, you offer them a modicum of discretion, convenience, and an opportunity for investment in potential problem resolutions.

For example, ask for suggestions to ease their documentation burden. This may come in the shape of a form or online tool, Buck says.

Action advice

It's a truism-some people just don't get it. Some physicians won't either. You tried talking with them and using friendly reminders and straightforward discussions, but still that one physician persists in improper documentation practices.

Begin exploring disciplinary options. Create an improvement tool-a form to document and track areas of concern, says Buck.

Submit the form to a disciplinary committee member, such as the medical director, chief radiologist, or your physician champion, for review and possible resolution.

Depending on your status within the facility or hospital setting, you may or may not have the "power" to do this, Buck says. "Administrators must provide support and enforcement for your efforts."

Insider sources

Stacie L. Buck, RHIA, CCS-P, LHRM, RCC, vice president, South-east Radiology Management, 512 SW St. Lucie Crescent, Stuart, FL 34994, 772/600-0324; stacie@southeastrad.com; www.seradmgt.com.

Stacy Gregory, RCC, CPC, president, Gregory Medical Consulting Services, 2661 N. Pearl Street, #364, Tacoma, WA 98407, 253/566-2494; stacy@gregorymedicalconsulting.com.

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