Making Coding Work for Your Practice

Barbie Hays, CPC, CPMA, coding and compliance strategist at the American Academy of Family Physicians, has simple advice on coding education: "Know your practice."

This means physicians should know the services they deliver and the associated billing codes that represent those services. While this may sound like an "overarching and lofty" goal, she argues that coding accurately is "essential to practice health."

In her work with physician practices, Hays has witnessed a tendency by many physicians to code lower than the level of care they're providing. There are a number of times she's audited physicians only to discover they're using CPT code 99211 when coding patient visits.

"Technically, a 99211 is considered in the coding world and in the physician world as a 'nursing visit.' A physician doesn't even have to be present in the room [to code a 99211]," she points out. 

Many physicians worry about their patients’ ability to pay for visits, so they under-code for emotional reasons, or they “want to be nice.” The other reason is ignorance, she laments.

Hays is referring to the belief by many physicians that if they don't code many “4” and “5” codes that get audited, then they are safe. The problem is, many physicians believe, incorrectly, that if they code 1s, 2s, and 3s that they won't be audited, she says.

Patients will be charged their copay and physicians could actually attract attention by consistently under-coding, which would put them below the bell curve with their colleagues across the country.

That’s why Hays recommends doctors code for the services they’re providing. “Code what you’re doing. Get paid for being a doctor,” she advises doctors. There are two reasons physicians need to code appropriately: Physicians need to stay in business and they also need to manage their own well-being.

"If you're not making money, if you're not able to pay your staff; if you're not able to pay yourself, then you're running into physician burnout issues, such as depression. It just spirals," she says.

Focus on Common Codes

Physicians need to focus on common ICD-10 and CPT codes. If 80 percent of a physician's practice is delivering E&M Services and Preventive Care Services, "they really need to know those codes inside and out." Experts also say physicians need to fully understand the documentation that's required to support those codes.

While there are 68,000 codes in the ICD-10 code set, the important difference between it and ICD-9 is the degree of specificity required in doctors' documentation, says David Wasserman, an advisor with the practice solutions and medical economics group at the Massachusetts Medical Society, where he consults with physician practices. For example, documenting a patient who is experiencing foot pain is no longer enough; physicians need to document their patient's specific foot ailment.

For this particular patient, the physician could choose from one of six possible ICD-10 codes, which include M79.671 (pain in right foot), M79.672 (pain in left foot), M79.673 (pain in unspecified foot), M79.674 (pain in right toe(s)), M79.675 (pain in left toe(s)), or M79.676 (pain in unspecified toe(s)).

Documenting appropriately requires the physician to zero in on their patient's ailment and then describe it in three or four words, says Wasserman. This, he adds, will lead to the appropriate diagnosis code. It's important for the physician to take their time when documenting their patient's foot pain. If their charts are audited, the physician could be in a position where they have to clean up their notes for months and even years.

Wasserman acknowledges that physicians don't have as much time as they'd like to spend with each patient, thus specificity in coding can be a challenge. His advice is to be as direct as possible when starting the patient visit. Specifically, physicians need to ask the patient the precise reason they're in the exam room. "Cut to the chase, but not in a crude way," he advises.

"The doctor is there looking at their watch, and they know they have 10 minutes. They need to determine what they're going to do about that [ailment] and [how to] document that," he says. Wasserman adds that it's best practice to update the patient record as soon as possible, otherwise the physician will be spending hours after work documenting their patients' care.

Try Paper

Wasserman recommends that physicians learn their top 15 diagnosis codes and put them on a cheat sheet near their computer monitor when they're coding patients' charts in the EHR. But physicians have to strike the right balance between the need to be diligent about documenting care thoroughly while refraining from copying and pasting from a previous encounter with that patient or other patients, he adds.

"[Copying and pasting] is a liability waiting to happen," says Wasserman. Instead, he recommends that physicians include as much nuanced information about individual patient encounters as possible. That's because once they've documented the patient encounter in the EHR, the practice's coder or biller will then need to review the codes and relevant documentation in order to prepare the bill to be sent to the insurance provider.

Along the cheat sheet theme, Hays has developed a paper-based, spiral-bound, condition-specific series of index cards for physicians to have handy as they're determining the appropriate ICD-10 codes for patient encounters. The diabetes card lists tips – such as a reminder that diabetes is no longer referred to as "controlled" or "uncontrolled" – and provides the appropriate codes for conditions as varied as "type 2 diabetes mellitus without complications," "type 2 diabetes mellitus with foot ulcer," and "type 2 diabetes with hypoglycemia without coma."

The beauty of the flashcards is they're paper-based, says Hays, who notes that they cover more than 1,200 codes. "My doctors and nurses want this on paper. [The flashcards] are easy to refer to and are organized in alphabetical order. You can make notes on the cards. You can't do that with an app," she adds. 

Her recommendation for physicians using the flashcards is to position them in the nursing station, at their desk, or anywhere they will be reviewing labs during the day and finishing their documentation.

While Hays touts her index cards, she says any physician practice could develop a similar paper-based system for prompting physicians with the appropriate codes. She recommends color coding the cards. While orange may not naturally be associated with diabetes, choosing that color for the diabetes card will train the physician's brain to understand that it's the diabetes card.

High-Tech Approach

Jessica Chen, MD, chief quality officer at ChenMed, a Miami Gardens, Fla.-based primary-care provider, says that her practice's physicians deal with many more than 15 to 20 codes on a regular basis. That's why, in addition to building its own EHR in-house, ChenMed also built a technology platform that asks physicians a series of questions about the severity of a patient's condition and then updates that information in the practice's EHR.

When a patient presents with knee pain, for example, the doctor is asked whether it is in the left or right knee and whether the patient has arthritis, in addition to other questions that will allow the platform to determine the appropriate ICD-10 code.

She uses coding for diabetes as another example. In this instance, the physician is asked a series of questions to determine the complexity of their patient's condition.

Once the coder at the practice receives the patient record, they then verify that the codes are correct, adds Chen. She's enthusiastic about the way this platform supports her practice's physicians.

Still, Chen acknowledges that any practice interested in implementing a similar decision-tree based platform needs to strike the appropriate balance between capturing the right information to determine the appropriate code and not overwhelming physicians with too many prompts within the EHR.

“ICD-10 is a lot more complicated [than ICD-9] and with value-based care, documenting the complexity of care and complications is important. There are guidelines for what physicians have to code for these complications, and what we try to do is make it simpler for our physicians to find the right code,” says Chen.