A Cast of Coders

"Documentation drives everything" is Georgette Gustin's mantra. Gustin is president of the national advisory board of the American Academy of Professional Coders (AAPC) and a longtime medical coder. Her conviction is well-founded: The Department of Justice collected more than $1.2 billion from healthcare-related settlements and judgments in 2001, its second record-breaking year in a row for collections. For the near future, the federal government will stay focused on containing costs by controlling illegal Medicare billing.

Gustin says that, because of this scrutiny and ongoing changes in the guidelines - in 1995, 1997, and more proposed - physicians need to "keep their fingers on the pulse of anything having to do with E&M," which makes up at least 40 percent of annual Medicare payments.

How to keep up with coding changes on top of treating patients, some physicians wonder? Get help, says Gustin. Coding should be a team effort, with physicians, coding consultants, and trained staff members each playing a part in this critical process.

Q: How can medical practices begin putting together a coding team that includes physicians, staff, and consultants?

Gustin: That's going to depend on the type and size of the practice and the number of patient visits. You could use any combination of those team members, with one caveat: that the physician has someone who upholds both technical and professional standards - somebody who is going to demonstrate the right ethics, who really understands the nature of the business, and knows what the risks are for not doing appropriate coding and documentation.

As part of passing the coding certification test, there's a certain obligation standard, just like when a physician gets his degree and takes the Hippocratic Oath. For coders, it says that we're going to do things professionally and ethically according to coding guidelines and principles.

Whether physicians rely on a staff person or a certified coding consultant, they have to have somebody who can keep up on all the regulations and research. There's a huge amount of time involved in that.

Q: How should practices go about keeping up with all the changes?

Gustin: At most practices, resources and time are very scarce - but in almost every [audit], we find there's nobody in charge of keeping all these updates together and communicating them. We tell practices they should be doing it on their own as part of a compliance program. The physicians have to have some role in the whole process because they have to understand what needs to be documented. That's where you have to work together in a team approach.

Coding changes are annual, but Medicare carriers generally change local medical review policy monthly. On top of that, you've got CMS [Centers for Medicare and Medicaid Services] sending out their transmittals, often on a daily basis. Somebody needs to be monitoring that, communicating those changes, and looking at how they impact the practice.

Q: How can practices be sure the coding process moves from the exam room to the front office without anything falling through the cracks?

Gustin: A standard process is that the charts are prepared based on the types of appointments on the schedule, and there is an encounter form or superbill - whatever type of document the facility uses - in place for each patient. The physician sees the patient, documents the service, and completes that form. In order to communicate the primary diagnosis to the staff - in effect, linking the ICD-9 and CPT codes - the physician can simply indicate that on the encounter form using a numbering system by labeling the primary, secondary, tertiary diagnoses with one, two, three, and so forth.

In some practices, there is somebody who is reading the physician's note and validating the encounter form before it gets put into the billing system. In others, it's going right into the billing system based on the physician's input. In that case, there's more review after the fact. There is a whole debate as to whether to do an audit before the bill is submitted or afterward.

Q: Where do you stand on that debate?

Gustin: There are advantages and disadvantages of each. I think it helps to do a combination of auditing before and after submission; it helps practices evaluate the entire claims process.

Also, be aware that there is a difference between auditing and abstracting codes for billing. Most groups today are auditing pre-billed services so they can adjust the code, if necessary, before the bill is generated. This helps to eliminate refunds and overpayments that might come out of retrospective audits.

Obviously, depending on the volume of visits, it's difficult to do that all the time. Some practices will look at a set number of records per doctor, per day, pre-billed, and keep that as part of a monitoring process.

And practices that are using electronic medical records tools for coding should do their due diligence up-front, and analyze these systems for accuracy annually, at a minimum.

Q: What happens if problems or mistakes in the coding process are discovered, and what can be done to avoid them?

Gustin: Auditing and monitoring is a huge issue. If you discover an overpayment, you have an obligation to repay. If the overpayment looks as if it's systemic or could have gone on for some time, generally, [legal] counsel gets involved. The problem will be evaluated by looking at the number of visits and whether there is a problem with your internal processes that you didn't realize - for example, that your staff was changing the codes before the bill went out.

The real key is that the form the doctor is using - the encounter form - is accurate. Physicians are not going to know all the CPT codes; there are just too many of them. They're going to rely on descriptions that accompany those codes. I've seen too many instances where the document is incorrect; the description has been abbreviated, and practices have gotten into trouble.

Q: What qualifications should an on-staff coder have?

Gustin: There have been a lot of people who once did appointment scheduling who, by default, have been given the code book and have turned into what practices call their "trained staff" because they didn't have other resources. But the person has to have some formal coding training as well as an understanding of medical terminology, anatomy, and physiology. They should be resourceful and detail-oriented, analytical, and have critical thinking skills.

Q: What kind of coding training is available?

Gustin: Physicians really need to ask questions because there are a lot of different options. They need to look at what the core curriculum contains. What is the focus of the training? Is the emphasis on the actual coding? People don't always understand there are different types of coding. When we talk about physicians' offices, we mean professional fee coding, as opposed to hospital facility coding. There are different credentials for hospital coders and physician coders. The hospital is generally billing for the resources and the room; the physician is billing for his professional services.

State medical associations, community, and vocational colleges are putting together medical coding specialist programs, too. They cover the gamut, not just "Insurance Billing 101." You need more than that because you have to tie in the terminology, the anatomy, coding principles, and medical records into one piece. And some of the vocational community colleges provide an opportunity to do an affiliation, or internship at the end of the course, to put your skills to work for a practice. So that's something to look for, too.

Q: What kinds of coding resources should a practice have on hand?

Gustin: Obviously they're going to need current CPT and ICD-9 code books. That's something a practice should get every year. The Medicare Physician Fee Schedule, published by the Federal Register is also very helpful; that comes out every fall and offers some insight into new codes and changes.

A lot of that information is also available on the CMS Web site (www.cms.gov). Nearly every Medicare Part B carrier has a Web site that includes new bulletins, and there are a lot of sites - for example, www.cignamedicare.com or www.medicarenhic.com - where you can do searches on local medical review policies.

Cheat sheets [summaries of coding regulations produced by pharmaceutical companies, other vendors, or internally] can be helpful if they are kept current. My concern is that, when we visit practices, the cheat sheet is dog-eared and looks as if it's been there for years. If they aren't updated annually, they are part of the problem.

Q: What should a physician look for in a coding consultant?

Gustin: They need to look at resumes, look for credentials - and check them. Unfortunately, there are probably some people who say they are credentialed, but how do you know? You need to call the coding organizations and verify, and make sure their credentials are current. If somebody is a good consultant, their clients will speak well in terms of how they delivered the work - was it timely, was it accurate?

The physician should ask a potential coding consultant: How do you stay up-to-date? How did you get your education? Do you have good understanding of clinical processes and operations? A good coding consultant will have worked in various clinical settings and will have a good understanding of the business operations of a medical practice.

Q: Is there an industry standard for productivity? What can and should a professional coder be able to accomplish?

Gustin: There are a lot of people coming up with what they think are best practices. But it depends on what the coder is doing. Is she just taking what the physician marked on an encounter form and double-checking that any hand-written codes are correct? Are there multiple locations and multiple physicians? Is the documentation dictated or handwritten? There are so many variables, and I think that's why we haven't seen a standard.

Often a coding consultant is coming in to validate what the practice is currently doing. The practice needs an independent opinion on whether they are doing the process correctly, to determine if they are missing anything. Is there potential risk they're not identifying, and are they leaving money on the table that they could be collecting? A consultant is there to provide education, make recommendations, and discuss policies and procedures the practice should have in place.

Q: How should physicians plan to keep their own coding education up-to-date?

Gustin: State medical associations are working to put out more sessions for physicians and the carriers are trying to give yearly updates. Specialty societies are becoming more active in coding. There are so many vendors, too - it's a very competitive industry.

At a minimum, physicians should get a yearly update on code changes that affect their type of specialty or practice - that's one to two hours of instruction coding annually. There may be some specialty-specific training, for example, in psychiatry.

It's easy to slip into old patterns, so it's important to get a refresher. If there's no one else in the office and physicians are relying on themselves, they may want to have more education. A lot of physicians say, "I know I'm undercoding, but I don't have to worry about it, they won't come after me." But that's not necessarily true.

No matter what course they take, physicians need to be careful. The OIG [Office of Inspector General] has cited some sessions in which inappropriate advice was given. So regardless of where physicians take a course, if they leave with some concept that would drastically change their overall process, they should probably get a second opinion. You don't want to just change your practice pattern; what you are taught could just be based on someone's misinterpretation of the regulations.

Questions? Write to editor@physicianspractice.com.

This article originally appeared in the March/April 2002 issue of Physicians Practice.