by Jeanne M. Chapdelaine

Since the advent of compliance plans, many physician practices have hired coding personnel to check and recheck the physicians’ coding. Some medical practices go so far as to compare every completed charge ticket to the physician’s documentation, which is a slow, resource-intensive process. Clearly, this delays charges and requires additional staff. What’s more, in our experience, it does not dramatically affect the accuracy of CPT coding; in fact, it often results in under-reporting (more on this below).

Such an intense after-the-fact check and balance effort suggests the revenue capture system is broken early in the revenue cycle. A more effective program is one that continually improves itself through regular, appropriate assessments, focused education, and consistent follow-through and support. It focuses on identifying potential problems before they occur and making continual improvements.

Pitfalls of the “manufacturing” approach

Many practices have implemented a “manufacturing” or production-style process of thoroughly assessing every charge ticket and/or piece of documentation. It’s clear this adds to a practice’s operating expenses, but ironically, this type of reliance on coding staff can also be costly in terms of unclaimed revenue.

This may seem counterintuitive, but we have found that most practices that have a production-style coding process also have physicians who put little, if any, thought into the codes they select, because they presume someone will fix their errors. It becomes an endless loop: the physicians’ coding worsens, resulting in more effort required by coding staff, making them so busy they cannot devote sufficient time to every case. When this occurs, many clinics simply add more staff.

The area that requires the most intensive efforts, but receives the least, is evaluation and management (E&M) service coding. Production-based coders simply do not have time (or, usually, the expertise) to truly “audit” every case, so if the physician’s E&M code selection is reviewed at all, it is usually just quickly scanned. This type of brief assessment rarely uncovers services that should have been coded higher. This is a surprisingly common occurrence; from our coding reviews, we have found more E&M under-coding than over-coding.

A tremendous amount of information can be documented in only a few sentences, but a quick scan usually erroneously leads to the presumption that the service should be coded with a low E&M level. Moreover, documentation nuances are critical to making or breaking the E&M code (an EMR can help significantly).  In a production-type coding situation, providers rarely receive feedback about the finer elements of their documentation. Usually, the coder just “fixes” the problem (i.e., reduces the level of service or lets a too-low level go through), and since production-type coders are focused on getting all their cases coded quickly, there is little time to work with physicians to help them learn how they should be selecting codes and documenting more effectively. In fact, many coders have never even met the physicians for whom they code!

Why make doctors code at all?

At some point, every physician has or will likely ask “Why can’t we hire coders to code everything so we can stop filling out charge tickets and just see patients?”

At first glance, this might seem like the most compliant approach to accurate coding. Also, taking the highest earners (the physicians) out of the process would seem to be the most cost-effective stance as well.

However, eliminating the physicians from the code selection process is not a good idea for several reasons. First, their names and provider numbers — not the coders’— appear on claims, so completely delegating this responsibility puts them at some risk.

Second, coders select codes based only on what they observe in physicians’ documentation. They have no way of measuring the providers’ actual effort beyond the documentation. When the physician is responsible to report the codes she or he believes to be appropriate, it gives the coder an indication of the level of service that underlies the actual documentation. If something is missing in the note, an education opportunity exists. If physicians are not given this opportunity, progress notes that are brief will simply be assigned low levels of E&M service by coding staff, and documentation that is simply missing an element will not be fixed in the future. Therefore, under-coding will continue.

Coders as customer-service agents

To be clear, we are not suggesting that coders don’t provide a necessary service or that medical practices should avoid employing coding personnel, nor are we suggesting that practices should stop reviewing documentation for appropriateness. The key is in how coders are used (i.e., technicians versus educators/communicators) and what their skills and services should be.

We have found the best model for coding support is for coders to act as “customer service” agents to the providers. By instilling a positive coder/physician team mentality and getting coders directly involved with ongoing monitoring and customized education, the need for a coder to be involved in every case is eliminated, and improvements become long-lasting rather than only for a given case.

Practices that have developed coder/physician teams have experienced reduced expenses (no need for a large team of “production coders”), significant improvements in revenue, and have dramatically taken daily control of their compliance risk because there are regular, focused, and useful interactions about coding and documentation appropriateness.

The best medicine: A coding liaison

One successful method is to devote a “coding liaison” or “coding compliance educator” (titles vary) to act as mentor to a certain number of provider constituents. For example, two liaisons might support 80 primary care physicians in four sites (each is assigned to 40 providers in two sites), while another supports 25 specialists across all sites. This approach ensures the sites and specialty are consistently supported and relationships can be developed, personalities understood, documentation styles mastered, preferences for meeting times accommodated, etc.

This ability to get to know each clinic’s or department’s unique culture and the providers’ idiosyncrasies results in more focused and effective communication, education, and support. It also creates an effective process for identifying issues that are common or consistent across the organization, allowing the practice to concentrate on its highest risks and vulnerabilities.

Practices have the most success when they understand that physicians learn better when using the following basic tenets (which can be easily applied when using the mentoring approach):
 

• The physician should be an active participant in his or her own education, not a passive recipient of the coders’ knowledge. One-on-one education is crucial.
• Education should be related to what the physician already understands (e.g., use the physician’s own cases as the learning tool). 
• Learning is retained longer when it is applied immediately.

Not surprisingly, physicians struggle when they are expected to learn coding from generic classroom-style training. The information “sticks” much better when they can discuss how they coded a patient visit that happened only yesterday.

Deploy your best coders to the front lines

The better-performing practices require that charge tickets be verified for accuracy and completeness as close to the site of service as possible. Some larger practices move their best coding staff to the clinical sites to be responsible for perusing every ticket before it is sent for processing and to provide real-time support to providers. These practices also require that each service provider (physician, nurse, lab personnel, etc.) indicates his or her service accurately on the ticket.

These front-end efforts eliminate the large volumes of charge tickets needing to be researched after the fact, or being returned to the clinical department to obtain missing information. To facilitate this, the team of coding liaisons might, for example, create a checklist for on-site staff’s use to ensure that each charge ticket is complete and ready for posting (e.g., referring physician’s name, linked ICD-9 codes, date of injury, etc).

Each coding liaison’s objective, simply stated, is to ensure that his or her constituents have all the tools and education they need to make charge ticket completion, coding accuracy, and documentation a simple and efficient process, and then to monitor and communicate results. To do this, a close working relationship with business office personnel (access to CPT frequency data, third- party payer denial trends, etc.) and the medical records department is required.

Create a coding team

Coding liaisons must serve as a team, reporting to one person and meeting regularly to share problems, findings, and to develop recommended policies and best practices. In addition, they must be actively involved with all other staff members involved in coding. The best person to recruit for this role may not necessarily be currently certified. He or she must have sufficient experience and expertise and be willing to prove it by testing for certification within the first six months of employment.

But a far more important attribute is the ability to see both the compliance issues AND the revenue opportunities, and to be able to communicate those effectively to physicians and staff alike. The type of person who can do this is typically a self-starter, not one who would be satisfied sitting at a desk and coding most of the day. This is a difficult position to staff; people with these mixed abilities are in high demand. For this reason, the better performing practices compensate them handsomely, offering perks and even bonus opportunities (not based on increased revenues, however).

Cleaner coding means fewer production coders

As suggested throughout this article, the proactive approach described here allows practices to reduce the number of (or eliminate the need for) “production coders” (usually through attrition) because the focus becomes front-end data collection quality. Information will be clean and accurate the first time claims are submitted, so another positive result is the impact on the business office’s performance (and tangentially, their morale). Third-party payer denials will be significantly reduced for such things as diagnosis code linking, missing modifiers, medical necessity, etc., therefore further reducing practices’ compliance risks.

Final thoughts

Some clinics focus their efforts on certain payers (e.g., Medicare and Medicaid). We discourage this, unless it is required by contract or previous agreement. How would your non-governmental payers view the fact that their claims don’t receive an equal level of respect for billing accuracy? A top-notch revenue capture process applies equal efforts across the entire universe of billings, because it identifies trends and education opportunities. If there is concern about a specific payer type, a focused review can be conducted.

In summary, revisiting how your practice handles the revenue capture/coding process only has an upside. The goal should be on preventing problems rather than continually fixing them.

Medical practices must determine whether their current process is built around the idea that it is an investment in efficient billing accuracy, or simply a cost (a likely increasing one at that) to be managed. Remember that with improved technology and the extremely sophisticated and complicated rules and regulations that exist today, a higher level of management and staff expertise will be required. The more physicians actively take responsibility to learn and understand how to effectively report their services, and to use their internal resources appropriately, the better performing their practices will be.

Jeanne M. Chapdelaine is a director with Partners Healthcare Consulting, a service of Wipfli in Minneapolis. She focuses on helping physician practices marry the intricacies of coding, reimbursement, and payer compliance issues to the realities of the practice of medicine. Her work typically involves improving the revenue cycle and ensuring that necessary technical expertise exists within a practice for excellent long-term revenue and compliance results. She can be reached at 952.548.3374 or jchapdelaine@wipfli.com.