COVER STORY

Demystifying the art of coding

It only seems like it takes magic to code claims accurately. Here's how some practices teach their doctors to circle the right numbers.

By Robert Lowes
Senior Editor

Hire a doctor fresh out of residency training and you may get someone who thinks 99214 is a ZIP code in Spokane—and nothing more. It's up to you to teach that rookie how to circle the right diagnosis and procedure codes on a billing slip. A lot is riding on how well you school him. If he undercodes, practice income suffers. If he overcodes, you risk running afoul of Medicare, which is itching to bust coding scofflaws.

True, some residency programs excel at teaching new doctors picky details like the need for an extended review of systems, among other things, to justify an E&M code of 99214. "But this is atypical," says coding consultant Joy Newby in Indianapolis. "Most doctors come out of residency guessing how they should code." Indeed, many are accustomed to letting a professional coder review their dictation and assign the right number.

So how do you make a competent coder out of a young doctor—or a veteran who should know better? You can send him or her to coding seminars, but that alone won't do the trick. Experts say every medical practice needs to take coding education in-house and make it a career-long experience through frequent chart audits and workshops. And doctors should figure prominently as coding mentors. "Physicians listen to physicians better than anyone else," says Cincinnati internist Douglas Magenheim, medical director of a practice management firm called MediSync.

Ten years down the road, if electronic medical records become the norm, doctors might be able to blow off Coding 101. Pioneering colleagues are already using software that guides them through the documentation process of a patient visit and suggests the appropriate code.^*

For now, though, automated charting or charge capture has yet to make significant inroads, so most physicians must master the admittedly arcane subject of coding. We interviewed doctors, consultants, and practice administrators on how to turn a coding novice into someone who isn't afraid of a Medicare audit.

When a new doctor knows zilch

With some new doctors, the subject of coding elicits little more than a blank stare. "I'll show a physician a 1-inch-thick book of CPT codes from the AMA and he'll let out, 'Oh wow,' " says Sherri Ash-Henson, director of clinical services for Alton (IL) MultiSpecialists. "Like he hadn't seen it before."

Ash-Henson decodes coding for recruits, and she can cover the basics—including the byzantine reasoning behind E&M codes—in two hours. Near the end of that initial training session, she tests the doctor's knowledge by having him read the dictation for actual patient visits and assign codes.

New doctors at Alton MultiSpecialists gingerly deploy their coding skills during their first few weeks of patient care. Because they're seeing only two to four patients a day as their practice builds, they have plenty of time to dictate model chart notes and mull over what code to use. Ash-Henson arms them with "cheat sheets" that break down E&M coding into the main components of history, exam, and medical decision-making, as well as their subcomponents. She also stocks each exam room with a book of CPT codes.

After a doctor's been on the job for a month, Ash-Henson audits most of his charts to determine whether the ICD-9-CM diagnosis codes and the documentation support the CPT codes. Established physicians at Alton MultiSpecialists also eyeball the first batch of charts, and Ash-Henson passes their comments to the new doctor.

Texas Gulf Coast Medical Group in Houston teaches a greenhorn doctor how to code by apprenticing him or her to a nurse. The latter accompanies the doctor on each patient visit, codes it, and explains what she did. "Within a few weeks, the doctor's able to code by himself," says Susan Waldron, the group's executive director, "although it takes six months before he's really proficient."

A new doctor at Texas Gulf Coast gets additional coding education from both the group's business office manager and a veteran doctor—usually medical director Ralph Tharp, an FP. "Doctors taking responsibility for coding is part of this group's culture," Tharp says. His involvement, notes Waldron, underlines the message that accurate documentation and coding are critical to the group's success.

Listening to other doctors is one thing. But how do you get physicians to heed nonphysicians about coding, which, for all its tedium, can be an emotional subject? Not only might a trainee resist the need to learn "rigmarole," he might react to a nonphysician pointing out that he failed to document, say, a review of lab results, by snapping, "Are you saying I didn't practice good medicine?"

Joy Newby anticipates this resentment. "I acknowledge that every minute we talk about CPT codes is a minute that the doctor isn't spending with patients," says Newby. "I also say that I never challenge the quality of care given to a patient. I'm only talking about paperwork."

Assessing how much a doctor really knows

Maybe the newly minted doctor whom you've recruited claims to understand coding. Or, you bring aboard a doctor who's practiced across town for 15 years. Surely he knows the difference between a 99213 and a 99214. In either case, you've got to assess the newcomer's ability and figure out where he might need further schooling.

Joy Newby recommends a baseline assessment. Let the new doctor see patients for three days and code each visit. Don't submit those claims to insurers right away, though. Instead, audit them and determine how well they were coded. Then review your findings with the doctor and bring him up to speed where necessary.

"The first thing out of my mouth would be praise for what the doctor's done right," says Newby. "Sometimes, the doctor turns out to be such a poor coder that you have to go with something like, 'You signed your charts like you were supposed to.'

"Then I'd bring up blatant mistakes, but characterize them as 'room for improvement.' Finally, to end on a positive note, I'd identify examples of documentation and coding that were pretty solid, but needed tweaking."

One round of auditing and coaching usually isn't enough for an inexperienced coder, says Sherri Ash-Henson. "I might meet with the doctor once a week for four straight weeks, and if he's catching on, taper off to one meeting a month and then one a year."

Another assessment and training technique is a shadow audit. The auditor is an expert coder who accompanies the doctor throughout a day of patient visits. While the doctor's coding the encounter, the auditor's quietly doing the same. At day's end, the auditor compares his codes to the doctor's, identifies the doctor's mistakes, and sets him straight.

You might worry that a shadow audit would disrupt doctor-patient encounters, but it doesn't have to. Simply introduce the auditor to each patient as someone who is helping the practice with administrative chores and ask if he can watch. "Usually the patient won't mind, but if he does, the auditor should bow out," says Todd Welter, a Denver consultant with the Medical Group Management Association. Dressing the auditor in a white coat helps put everyone at ease.

Squeamish about bringing a coder into the exam room? Have the auditor review the completed charts and compare notes with the doctor at the close of the day—akin to Newby's assessment approach. However you do it, shadow auditing is a powerful teaching tool because patient encounters are still fresh in the doctor's mind, says Kathleen Sharp, a coding and reimbursement analyst with Northampton Physician Services in Wilson, PA. "When you audit a chart and show it to the doctor six months later, you're not as likely to get your points across," says Sharp.

Say Yes to CCE— continuing coding education

You have two compelling reasons to be a perpetual student of coding. One, constant testing keeps you sharp. And two, the rules for coding—whether they come from Medicare or your local Blues—change from month to month. So you have no choice but to embrace continuing coding education.

Periodic internal audits are one form of CCE. Douglas Magenheim recommends a monthly audit consisting of five charts for each doctor. "Let the doctors audit each other," adds Magenheim.

Here's an easy—and tested—auditing technique. Once a week, pull two or three charts per doctor at random from the past few days. Then, over lunch, discuss the charts and, doctor by doctor, propose a code. Afterward, have the doctor who dictated the chart disclose how he actually coded the visit.

Such miniaudits worked wonders for the four FPs at Inlet Medical Associates in Murrells Inlet, SC. Lessons learned have translated into a claims-rejection rate of merely 1 percent, less undercoding, and a 3 percent boost in collections, says practice administrator Lynn Heckerman.

In a testimony to the power of technology, though, the group dropped weekly chart audits after converting to an EMR program last year. The software automatically assigns a CPT code—but no modifiers—to a patient visit based on the doctor's documentation. Physicians must decide whether to put that code and any modifier on the paper Superbill. "The EMR is the best coding educator because it teaches coding during every visit," says FP William "Jackie" Epperson.

Still working with paper charts, doctors at Texas Gulf Coast Medical Group undergo coding audits in quarterly meetings of what they call revenue teams. Each doctor has a coding team that includes his nurse, scheduler, and insurance claims specialist along with the business manager.

In addition to updating the doctor about his collections, team meetings delve into coding patterns. "If a doctor is trending toward 99214 or 99215 visits—and trending at any level can make a payer suspicious—we'll conduct random audits to see if the documentation supports these higher codes," says Susan Waldron.

In-house workshops get doctors to the point of dreaming about CPT codes at night. Texas Gulf Coast holds two group-wide workshops a year. Alton MultiSpecialists does twice that many. Kathleen Sharp calls this a laudable exercise, but advises practices to tailor such workshops to individual specialties.

"Coding is very specialty-specific, even when it comes to evaluation and management codes," says Sharp. "After all, each specialty looks at different organ systems in an exam.

"It's harder for an instructor to teach a mix of specialists than one specialty. If the instructor fields a question from an orthopedic surgeon, the eyes of the internists and dermatologists are likely to glaze over. You lose your audience."

Outside workshops come with red flags

There's no shortage of seminars that doctors can attend for the sake of continuing coding education. Virtually every specialty society offers them, either at annual conferences or in stand-alone venues. Private organizations and consultants also get into the act. The coding-workshop circuit, by all accounts, has its shortcomings. It's hard for a doctor to retain mounds of information dumped on him over a day or two without the benefit of systematic follow-up. The helpfulness of the information also varies.

Workshops sponsored by the American Academy of Family Physicians and other primary care groups have a good reputation, says retired plastic and reconstructive surgeon and consultant David Zehring in LaVeta, CO. "When you get out into the specialties, coding education becomes a little more problematic."

Case in point: Sherri Ash-Henson at Alton MultiSpecialists recalls how a pediatric society told her pediatricians that they could charge insurers extra for an eye exam done during a physical. "The charge may be legal, but nobody paid for it when we tried," says Ash-Henson.

Other coding seminars lead doctors astray by promising to dramatically boost their income through higher coding. "Stay away from them because you'll probably be given misinformation," says Zehring. In a recent investigation, the US General Accounting Office taped consultants—hired by a big-city medical society—who taught doctors how to artificially generate chart documentation for the sake of better-paying CPT codes. Doctors who illegally upcode, of course, invite fraud-and-abuse prosecution from Medicare.

Chicanery notwithstanding, legitimate coding seminars have their place. Small practices may not have the administrative infrastructure to conduct their own in-depth classes. Education sponsored by organized medicine or reputable private firms reinforces the importance of proper coding in the doctor's mind.

And who knows? The doctor who couldn't understand how to use a CPT modifier may finally catch on during a workshop in San Francisco.

*See "How the device in your hand can put more money in your pocket," Dec. 17, 2001.

 

Robert Lowes. Demystifying the art of coding. Medical Economics 2002;7:140.