Coding can be a dense and Byzantine process. Doctors hate it. The worst of it is that every payer seems to have its own take on coding.
But you can't bill for services without coding for them. And as Medicare's pay-for-performance program catches on and private payers follow, correct coding and documentation are more important than ever.
Bottom line: If you want to get paid correctly for the work that you do, you must understand the rules.
We turned to several procedural coding professionals — experts who advise physicians, medical practices, hospitals, and other providers — and asked two questions:
First, what are physicians doing most often to undermine their own coding and documentation efforts? In response, our experts offered nine big coding blunders that physicians could and should fix today.
"I see many physicians stuck in the mind-set that what they learned about coding 10 years ago is all they need to know," says Rhonda Buckholtz, vice president of business and member development for the American Academy of Professional Coders. "A lot of times their knowledge of coding is outdated."
Second, we asked them to describe the emerging trends and possible coding rule-changes likely to affect physicians' lives in the future. (See textbox "Trends.")
Straight from the experts, then, here are the tips, peeves, and predictions we heard most often.
1. Failing to note negatives
There's far more to assessing a patient than listing the chief complaint. Noting the pertinent negative findings — ruling out what's not involved — is a fundamental part of the diagnostic process. So why not get paid for it? Unfortunately, physicians can slip up when documenting this aspect of their thought process, says Margie Scalley Vaught, a coding consultant based in Chehalis, Wash.
"To give the proper CPT code for the office visit, it comes down to what did you touch and what was the result," Vaught says. "If you leave out some of the negatives you could end up with a lower-coded visit even though you spent the time and did perform an exam that deserved the higher code."
Let's say you've seen a patient who complains of knee pain and limited range of motion. Your examination finds no lesions or rashes, no signs of injury, neurological impairment, or pain to the touch. If you state in the record merely, "knee pain and limited ROM (MS)," you've just cost yourself money. That short recitation of just the positive findings is a problem-focused exam covering just one organ system, which is a lower-level code.
"When it comes to coding and billing, both positives and negatives are at work," Vaught says. "You have to go beyond saying 'patient has limited range of motion and pain with palpation,' and mention the other aspects of the knee and other areas that you examined but had negative findings."
No payer, or coder for that matter, will just assume that you also checked the patient's pulse, sensation, or looked for a rash or lesion. That's three more organ systems — a detailed exam under the 1995 rules or an expanded exam under the 1997 rules. All you had to do was describe those pertinent negatives in the record as something like: "negative for rashes or lesions" (Integ), "no effusions," "normal pulses" (CV), and "normal sensation" (Neuro). Presto: The proper code for the appropriate exam level you did is applied.
2. Skimping on substance
Vaught urges physicians to be especially wary of unintentionally downcoding follow-up visits for established patients. That patient's knee-injury follow-up would be a 99212 if your note says: "I'm seeing Ellen back today regarding the left knee injury three weeks ago. She's been going to physical therapy, has no complaints. We're going to see her back in a month."
It's an adequate note, but was that really all you did? What about your assessment that supports your treatment plan? Mentioning them would lead to a note like this: "Ellen's been going to physical therapy and icing her knee as instructed. She's used the brace as recommended for the past three weeks with no complaints. She is going to continue physical therapy, bracing, and using over-the-counter medications as needed for pain, and she'll call us if she has any problems."
OK, it's a bit wordy but isn't that what you did? If so, you've got a 99213 visit.
Vaught also sees oversimplification happen when physicians interpret other physicians' records or tests they've ordered. An assessment and medical plan in the patient's record should state your diagnosis and the rationale for your treatment plan, test, therapy, or other orders.
"Put it in the note if you discussed options with the patient or what you intend to do next, whether it's therapy, or continue watching, or discussing surgery," Vaught says.