In order to have its coding needs fulfilled, a practice could hire a part-time or full-time coder, or it could outsource the work.
When trying to decide which avenue to go, Richard J. Lucibella, CEO of Accountable Care Options, LLC in Boynton Beach, Fla., a direct risk contractor with CMS for Medicare patients, advises practices to base it on panel size and composition. "Consider the number of patients you see per day, the mix of insurance payers, and your involvement in pay-for-performance programs," he says.
If you have a single specialty practice only involved in fee-for-service reimbursement, it is quite possible that periodic training of internal staff, combined with a random chart audit will render external and perhaps even internal coders superfluous, Lucibella says. Existing staff members are oftentimes looking for advancement opportunities and there are plenty of resources available.
"Contracted accountable care organizations (ACOs) and HMOs will often provide extensive coding training and support," he says. "Therefore, [ACOs] generally look to our office administrators, medical assistants, and billing staff and offer them the resources necessary to obtain certified coder status. In this manner, the practice can grow into coding functions in a more fluid ramp up — adding staff only as [it] identifies needs."
If a practice requires coding expertise only for reporting CPT and G-codes (codes that report functional status such as mobility, cognitive ability, and self-care), then an external coder might be a good option. For larger practices, including those reliant on Medicare Advantage, commercial HMOs, or commercial and Medicare ACO programs, the importance of knowledgeable and experienced coders increases, Lucibella says.
Physicians should also consider the effects of value-based care and the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) when deciding whether to use an in-house coder or outsource coding needs.
Maxine Lewis, president of Medical Coding Reimbursement Management, a company specializing in coding, reimbursement analysis, auditing, and compliance, and a member of the National Society of Healthcare Business Consultants, says MACRA will initiate the cost component to the Merit-based Incentive Payment System — which eventually will become 60 percent of the total MIPS score. This component will be based not only on bundled payments and the hierarchy of codes, but also episodes of care.
"A coder must understand the initial, subsequent, or sequel of the encounter, adding to that any referrals or additional treatment that will contribute to the diagnosis' cost," she says. "Providers will be responsible not only for the cost of their services, but also for others that are associated with the specific diagnosis. Keeping coding needs in-house will provide greater access to the referrals and any additional cost factors that may relate to the practice."
In-house: Employing Coders
There are both advantages and disadvantages to having coders on staff at a medical practice. Barbara L. Hays, CPC, coding and compliance strategist at Leawood, Kansas-based American Academy of Family Physicians (AAFP), points out that in-house coders allow for improved communication and education between the physician and the coder, as well as staff such as the front office and back office.