Coding Dilemmas Cracked

Like many physicians, Dr. Yoash Enzer does what he can to understand coding. He takes classes and gets new coding books each year. But -- like most physicians -- he finds the rules cumbersome and vague. The best thing he can think to say about coding is that it's "a necessary evil." 

"[It's] impossible to determine the right code to use," complains Enzer, an oculoplastic surgeon from Providence, R.I.

"If a doctor wants to survive and take care of patients, he or she has to get paid, and the only way to get paid is to code appropriately. Furthermore, if you code incorrectly you face, at best, civil liability, but also possible criminal liability for fraudulent billing. It's a very serious issue," he says.

This isn't news to readers of Physicians Practice. But even for the most conscientious physician (or coder), it can be hard to get it right all the time. According to the Healthcare Financial Management Association's "Tip Sheet: Medical Claims Denial Management," the error rate for CPT coding is 45 percent to 55 percent.

Some specialties have it worse. Interventional radiologists, who use a particularly complex combination of codes, get their coding wrong 82 percent of the time, according to the March 2003 issue of "Healthcare Biller: The Communication Network for America's Health Care Billers," a monthly newsletter from Aspen Publishing.

Such errors result partly from the sheer volume and intricacy of the coding rules. But practices also too often rely on coding custom rather than coding knowledge.

"People have a level of comfort in doing things the way they've always done them. They have no idea that the thing they've been doing was right 10 years ago but has been wrong for the past eight years," says Nancy Enos, director of physician services for Lighthouse MD, a reimbursement management and coding education company in Providence, R.I.

"Credentials are really important," she adds, encouraging accreditation from the American Academy of Professional Coders as a good way to make sure staff is as expert as possible.

"Someone with a lot of experience but no ongoing education is apt to repeat the same errors over and over again. Experience doesn't really mean competence."

But competence doesn't have to be as elusive as you may think. We can't teach you everything about coding in the space of one article, but we can give you a keener set of eyes. Read on to find out four common types of coding problems that might well be happening in your practice. Avoid these, and you'll be well on your way to higher coding competence.

Start with the right form

In most offices, coding starts with the encounter form, superbill, or other charge capture form on which the physician circles or checks a CPT and diagnosis code from a list. That serves as a receipt for the patient as well as the initial instructions for the billing team who, basically, send out a claim based on what the physician circled. Simple enough. The problem?

Too many of those forms are outdated, incomplete, or just plain unclear. That starts the entire coding and billing process off wrong.
Keep in mind that the CPT codes change every year, and your forms may include codes that were deleted or updated a year or even five years ago.

Your superbill, charge ticket, or encounter form --  whatever you call it --  should be reviewed at least annually. Buy a new CPT and ICD-9 book each year, as early as possible, and review all the codes on your forms.

Your charge ticket might not even include the codes you should be using. For example, Enos describes visiting a specialist office that had only codes for established and new patient visits on its form; consults weren't an option for the physicians to choose.

"I know they are a specialist office. Patients are being referred by a primary-care provider for consults," Enos points out. Yet all consults had been incorrectly billed as new patient visits, even though consults pay better.

Also, be sure your encounter form is not being used as a replacement for official CPT manuals. It seems easier to simply refer to a list of the commonly used codes with a short description than a big book of codes with paragraph-long requirements. But this is like reading "Cliff Notes" instead of Moby Dick itself.

Usually, the descriptions on charge forms are extremely brief, and physicians may not realize -- or may gradually forget -- what the code really stands for. They get so used to the abbreviated explanation they don't even consider that there is a longer, official version. Everyone should read the full account at some point.

Emily Hill, PA, president of Hill & Associates, a coding consulting firm in Wilmington, N.C., suggests that physicians and coders sit down together to review each description, create a summary, and determine how to use it properly for services their practice commonly provides.

Learn office visit basics

In most practices, the evaluation and management (E&M) codes used to report office visits are the most commonly used codes --  and also the least understood.

"I think the hardest aspect of coding is office visits," Enzer says. "There are many, many criteria that go into deciding which level of five codes to use." Given the time it takes to do it right, he says, "there would be no way to see enough patients to keep in business. It's a no-win situation."

"Across the board, E&M coding has the greatest impact on all specialties," agrees Crystal S. Reeves, CPC, a consultant with the Coker Group, a consulting firm based in Atlanta.

Specifically, physicians tend to underestimate the complexity of what they do, says Reeves. "They underestimate the complexity of the medical decisionmaking they have made for that visit because they make that decision every day ... . For example, managing three chronic illnesses is a moderate risk. Conversely, some specialties --  I'm thinking of cardiology or oncology --  deal with high-risk patients, but not every patient is a level five."

Here are some tips to help you code office visits more accurately:

Capture new patients -- New patient visits are visits with any patient who has not been seen in the practice by someone of the same specialty for the past three years. Even if the patient has a chart in your practice, if he hasn't been in for three years, he is a (lucrative) new patient. And even if the patient came to your multispecialty practice last year to see your orthopedist and now is visiting your internal medicine specialist, he is a (lucrative) new patient. Don't miss these.

Coding for time -- The official CPT descriptions for office visits include a suggested length of time. For example, the description for 99203 says "physicians typically spend 30 minutes face-to-face with the patient and/or family."

It's easy to get the impression that 99203 requires a 30-minute visit. However, you can still use this code if your visit lasts just 25 or even 15 minutes but meets the other requirements for the code --  a detailed history, detailed exam, and medical decisionmaking of a low complexity.

"These represent typical times which may or may not be met during any given encounter," Hill says. "So if you are billing based on the extent of your history, exam, and medical decisionmaking, the time is really just a reference and is irrelevant to actually selecting a code.

"The flip side of that is a patient for whom you may do a very limited history or medical examination, but you end up spending a significant amount of time on counseling. Now time becomes the determining factor."

Selecting a level --  Each set of office visit codes -- new patients, established patients, consultations, etc. --  includes codes representing increasing levels of complexity, from level one to level five. This, of course, is what causes the most headaches when it comes to E&M coding. There really isn't a shortcut. To pick the right level, you need to understand what it requires. However, once you've read and understood the requirements documented in your CPT manual, try using a cheat sheet for on-the-fly coding, such as the sample on the following page. (Or go to www.PhysiciansPractice.com, scroll down to "For Internal Use," and download the E&M Coding Worksheet.) Then, check yourself regularly.

"It's important for practices to run their E&M distribution per physician on a regular basis ... to make sure that they haven't fallen into the habit of reporting the majority of their services with one code," Hill recommends. "A lot of people love the [code] in the middle."

Indeed, when the Medical Group Management Association studied the coding profiles of family practices, it found that 23.45 percent of all reported codes were 99213s. 99214s represented just 4.17 percent of codes. In internal medicine, 99213 was also the most-used code, representing 18.46 percent of the total.

Classically, E&M coding follows a bell curve, but there may be a good reason your results don't follow that norm, Hill notes. "For example, if you have an elderly population and you manage a lot of chronic illnesses, your curve is going to look different from the new physician in practice who is trying to get established and is seeing a lot of minor acute care problems."

(You can compare your statistics to Medicare norms by using the E&M Coding Calculator under "Calculators" in the Tools section of www.PhysiciansPractice.com.)

Using 99211 -- Of all the E&M codes, 99211 is the most abused. This low-level, established patient visit has very ill-defined requirements, and practices tend to use it more liberally than they should.

99211 should only be used if there is an office visit that is medically necessary. Instead, physicians and billers like to report it in addition to or in place of less lucrative but more accurate codes.

The most common area for this mistake? Injections. Practices may see a patient who has come in for an allergy or flu shot, but they may also check blood pressure and weight and call it an office visit. If there is no reason to do an office visit --  if all you need to do is deliver a shot -- don't embellish the services in order to use the 99211. You should code injections using the CPT code for administering the injection and a J code for the supplies used.

Again, the services reported have to be medically necessary. "Are you just doing it so you can fill in and get paid for the 99211? If you didn't get paid for it, would you do all that anyway?" asks Reeves.

Use your modifiers

Proper use of modifiers can make or break your denial rate. However, "staff often neglect to use modifiers or use them wrong," Reeves says.

You can find a full list and description of all the modifiers in an appendix of your CPT coding manual; here are some of the most commonly misunderstood modifiers:

Modifiers -62 and -80 --  Don't get these confused. If there are two surgeons doing distinct parts of one procedure, each surgeon should report his service with a -62 modifier. However, if there are two surgeons present at a procedure and one is acting as an assistant, use modifier -80 (or -82 if a surgeon is being used as an assistant because a qualified resident surgeon isn't available).

Modifiers -76, -77, and -91 -- The repeat procedure modifiers. Modifier -76 indicates that the procedure reported is a repeat procedure by the same physician (and not a second claim for the original service). Modifier -77 similarly explains that the procedure was repeated, but shows that a different physician did it the second time around. Use modifier -91 when repeating a diagnostic lab test on the same day the test was first performed. "There are a lot of denials for duplicate claims and, in some cases, a -76, -77, or -91 modifier might have explained the circumstances," according to Hill.
Modifier -59  -- The distinct procedure modifier stresses to the payer that although the reported procedure may seem repetitive or part of another procedure already reported, it is actually a distinct procedure worth payment. For example, a physician may need to explore a traumatic wound in a patient's back and in a patient's abdomen. Both procedures are coded using 20102; attaching the modifier -59 to one of them shows that there was no overlap in the service as it occurred in two separate areas of the body. "Modifier -59 says, 'I deserve to be paid for this because it's in a separate body area or completely separate from the first. [I]t's one that can be abused ... . You need to use it with caution," Hill says.

Remembering to add the right modifier can be hard enough, but the process gets even more frustrating when different payers refuse to recognize different modifiers, forcing billers into a coding guessing game. The best approach? Don't play their game. Just bill according to the CPT guidelines.

Enos says that if the chart supports the use of the modifier, practices should use it, regardless of payer policies. "Yes, payers are going to be inconsistent in their reimbursement policy, but I always say ... you shouldn't bill according to who the payer is ... . You should code payer-blind ..." she says.

Pay attention to diagnosis

The CPT coding system gets so much attention it's easy to neglect the other part of coding --  the diagnosis, or ICD-9 codes. But using those codes conscientiously means far fewer denials for lack of medical necessity. You need to use them well to tell the payers why you did what you did.

Using them well means using the most up-to-date code. Like CPT codes, ICD-9 codes are updated annually. Get a new list of codes each year, read it --  and be very specific when you pick a code.

"Anything ... not coded to the highest level of possible digits will become a rejected claim ... If there is a possibility of a five-digit code, you have to use that instead of a four- or three-digit code," Hill advises. That is, don't use 221 to report a benign neoplasm of "other" female genital organs if you can be more specific and report 221.0 for a benign neoplasm specific to the fallopian tube.

Getting this specific is more challenging than it appears at first glance. Physicians and coders should take time to carefully review the full list of possibilities in a diagnosis category instead of choosing the first one they come across.

Finally, good use of diagnosis codes means connecting them to service and procedure codes.

"You have to make sure that for every CPT code you submit, you have selected an ICD-9 code that supports the need for that service. Not only does the physician or provider have to identify that, but the person filing the claim needs to make sure they link the ICD-9 to the CPT code on the claim form and ...    just with the procedures to which it applies," Hill says. For instance, it's common to get a denial from Medicare if a physician provides three services during a visit but only provides an ICD-9 code that makes sense for the first two services.

To be sure, coding is a necessary evil, as Enzer says. It can be complex, time-consuming, and frustrating when it never seems to go right. Still, focusing on and correcting just a few basics can go a long way toward better coding accuracy and payment that reflects the work you've done.

Pamela Moore, PhD, CPC, is senior editor, practice management, for Physicians Practice. She last wrote about our annual Fee Schedule Survey in the January issue. She can be reached at pmoore@physicianspractice.com.

This article originally appeared in the March 2005 issue of Physicians Practice.