Medical coding is an abomination. A Kafkaesque quagmire. A dismal science intended to prevent physicians from getting paid for what they do, and which induces obsessive-compulsive disorder.
Ever had such thoughts? Probably.
Unfortunately, coding isn’t going away; even the most ambitious healthcare reform plans don’t envision its demise. So, however much you may loathe coding, you still need to know how to do it well if you want to get paid what you’re owed. And to be good at coding, you need to be on guard against the bad habits and rationalizations that develop as you seek shortcuts through a complex subject.
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You should also know what the Medicare audit police are focusing on in any given year, and understand the new directions in healthcare policy and reimbursement that will change how you’ll code in the future.
But we’ve got you covered. We interviewed a bevy of coding pros for advice that will burnish your skills and help you submit accurately coded claims. Improvement in this bothersome aspect of medicine will reduce denials, avert audits, and maybe even boost your revenue. And when you get good at something, it gets easier.
Sound like it might be worth your time?
Let’s get started.
The roots of undercoding
Medical coding is rational, in theory. Do this, this, and this for a patient with this condition, and document it properly, and you’re entitled to get paid for what you did. The code is really just shorthand. In practice, however, doctors frequently code by emotion.
Some kindhearted physicians, for example, undercode a 99213 office visit with an established patient — marking it as a 99212 — to reduce what a Medicare patient owes out-of-pocket, which is 20 percent of the Medicare allowable once the deductible is met, says coding consultant Bill Dacey in Stanley, N.C. The problem is that doctors who do this cost themselves more money than they save the patient — a lot more.
By picking a 99212 instead of a 99213, the doctor saves the patient $4.83, but foregoes $19.33 in revenue (see the table below). “This sensitivity to Medicare patients carries over to commercially insured patients, with more undercoding as a result,” says Dacey.
Besides surrendering revenue, these intentional undercoders risk being charged with Medicare noncompliance, even though the government comes out ahead financially. So what’s a compassionate doctor to do when his patients can’t afford his fees? “Code the visit right, and address the patient’s finances afterward as a hardship issue,” says Terri Fischer, a healthcare consultant with CPA firm LarsonAllen in St. Louis. “Medicare lets you waive a patient’s coinsurance if you have a hardship policy, and the patient satisfies its criteria. You must apply this policy to all your patients, though, not just Medicare recipients.”
Another emotion that leads to undercoding is fear. “Some physicians will code every office visit as a 99212 just to stay under the radar and avoid a Medicare audit,” says Ginny Martin of Healthcare Consulting Associates of NW Ohio in Waterville. “However, coding everything the same can initiate an audit as well.”
Other types of undercoding are unintentional, but just as detrimental to revenue. Dacey says some physicians become victims of their own clinical prowess. They see lots of patients with multiple chronic illnesses, many of whom qualify for a 99214 office visit. “These doctors become so good at treating complicated patients that they view them as commonplace, not so hard, and they mentally classify them as 99213, which is right in the middle,” says Dacey. The solution? Code scrupulously and give yourself credit for the work you do.
The roots of overcoding
While you must guard against undercoding, Medicare data suggests that, for evaluation and management services, overcoding is far more common. Medicare providers overcode with the ubiquitous 99213, for example, almost twice as often as they undercode with it, according to the latest claims error data from the agency.
One antidote to overcoding is rejecting the conventional wisdom that says the intensity of your service — and your documentation — earns you a particular E&M code. To be sure, you must always hit your marks for the history, the exam, and medical decision making, with each of these components having its particular level of intensity per code. You’d appear to qualify for a 99214, for example, if you recorded a detailed history and detailed exam (for this office-visit series, you only need to measure up on two of the three components). “But an auditor might ask, ‘Did you need to do all this stuff? Was it medically necessary?’ ” says Bill Dacey. “You can’t manufacture a 99214 from a hangnail.”
