Coder beware

Encoder options abound. But keep in mind that these tools are only as good as the folks using them.

Lehigh Valley Physician Group, a Pennsylvania multispecialty practice with more than 300 physicians, uses CodeCorrect, but Kathleen Sharp, the quality improvement adviser for the group, still relies heavily on people power. “We acknowledge it as a tool, but just like any tool, you want to make sure the person using the tool knows how to use it. A hammer is a wonderful thing, but you can do a lot of damage if you don’t know how to use it properly.”

Wendy Johnson, who also uses CodeCorrect as compliance manager for Sharp Healthcare in San Diego, agrees. “You really need some baseline knowledge. I prefer when some person can look at the codes and select the right one. You may see a lot of denials if you assume the computer is right, and then you are not sure where the problem is.”

As part of her shopping process, Sharp had her staff use various products and compared them head to head. The expert coders could use any of them with good accuracy, but the novices had trouble with some systems.

“When we had folks in our coding and compliance department test [the products], they could tell very quickly when the systems were getting them to the right code. When we rolled it out further, we found people typing in other terms that made it less useful or it took too many clicks and they weren’t likely to use it,” Sharp recalls.

Here is an example of why people matter despite the best technology: Say a physician documents that he had a nurse infuse a dehydrated patient with a bag of glucose solution. A beginner could type “glucose” into some search engines and find various glucose tests for diabetics but nothing for infused solutions. The coder would have to know that the solution used was actually probably dextrose and confirm that with the physician, or would need to know enough to try “dehydration” as a keyword instead.

Another software shopping tip: Look for hardware while you’re at it. “If staff or physicians have to travel across the office to a shared computer to use the software, you might as well have a book locked in a cabinet,” says Sharp. Her physicians all access their encoder Web site from pen-based tablets they carry with them. “Otherwise, in the flurry of the day, it just won’t happen.”

Overall, though, Sharp is pleased with her encoder. “We do know that we are capturing services that we otherwise would have missed. People will put something in, and the system will tell them, ‘You really are looking at two codes, not just one.’ Also, the claims are cleaner, which means faster turnaround times.

“It has also helped us in the appeals process. For third-party payers that don’t publish their guidelines, we can easily pull up the Medicare guidelines and say [in an appeal], ‘This is how Medicare says to bill.’ They don’t always pay, but if they come back and say, ‘Our policy is different,’ they sometimes produce their unpublished guideline. We keep that policy in our records, and understand that payer better for future claims.”

Manage revenue

So encoders help physicians and staff pick the right code according to the CPT rules, but correct coding and good billing are not necessarily the same thing. That’s because of the varied demands of different payers and the relative complexity of filing thousands of claim forms accurately. That is where the second category of tools for coding help comes in: advanced claim scrubbers and revenue-cycle management products.

“Once you’ve selected a code, we can tell you if the codes you’ve used are appropriate for the payer you are billing,” says Jim Denny, president and CEO of Navicure, a revenue-cycle management company.

Here’s how it works. A practice sends claims through Navicure’s secure Web site. “The claims are edited in real time as they are received. We apply standard types of edits: CCI edits, NCDs, payer-specific data, too,” Denny explains. Such systems typically also scrub claims looking for blank fields, missing place-of-service codes, and confirm that the diagnosis and procedure codes link up. For their part, payers use similar products on their end to screen claims containing errors for quick denial.

In short, revenue-cycle management products get claims cleaned up before they ever reach a payer, reducing denials down the road, and educating staff about how to fix problems ahead of time. They are like really smart claim-processing centers merged with some elements of a practice management system.