The Coding Conundrum

Who should code? Physicians, staff or someone else?

Like it or not, today's physicians no longer have the option of throwing up their hands and saying: "I'm a doctor, not a businessperson. I don't want to have anything to do with coding." The ultimate responsibility, if an error is made, is always the physician's. And it is the physician who can get audited -- not the billing person or the certified coder. Despite shouldering the burden, physicians' involvement in the coding process varies across practices. Thus, the debate remains: who should code? Ideally, most experts say, coding should be a shared responsibility.

Todd Welter, president of R.T. Welter & Associates, a consulting group in Denver, suggests that physicians at least code all of their office visits and hospital visits. "Documentation is being examined very heavy-handedly. Some insurance carriers are out to see a doctor's head on the wall." He believes even though the E&M Coding Guidelines may be poorly written, physicians can learn the concepts and make accurate coding part of their regular routine.

Welter points out that if the federal government suspects cheating, it will fine the physician $10,000 per line item if the coding was done incorrectly. "That's why physicians have been forced to become record keepers and practice medicine differently than they ever intended. Therefore, it's important that the physician, the nursing staff, the office manager, and the people doing the coding all be trained at the same time."

Sharing the burden

Administrator Charlene O'Rourke, of North Kansas City Internal Medicine in Kansas City, Mo., says the key "is making sure we are applying the correct codes and the correct diagnoses to the service for reimbursement. We use a three-part charge ticket. The physician puts the diagnosis -- not a code number -- on the charge slip. The physician then keeps a copy for review when dictating into the medical record, to prompt his memory about the specifics of the visit. If there's ever an audit, we can prove this is the reason why the physician ordered this particular service."

The practice, which has seven physicians and two nurse practitioners, uses data entry staff who have been trained to do the coding, while a certified coder audits to make sure the staff and physicians are accurate. "Ideally, you'd want the physician to do the coding, but realistically it doesn't happen," O'Rourke says. "However, staff members are taught to question the physician: 'Is this the diagnosis you want to use for the lab study?' 'What diagnosis do you have that will support the chest X-ray?' 'The diagnosis that you wrote down doesn't support the service.'"

Scott Orthopedic Center in Huntington, W.Va., has nine full-time and two semi-retired physicians. Of the full-timers, two carry a coding book with them for their surgeries so they can write out the CPT codes and select the diagnosis codes. They give this to the in-office coders who double-check the information before billing.

In the office, codes are chosen by the nurses or the doctors, and either can mark the superbill. One of the coders uses monitoring software to confirm that the CPT and ICD-9 codes -- the service and the diagnosis -- match. The simple cases are billed immediately, while the more complex ones are double-checked with the surgeon.

"There are numerous disadvantages to physicians being the only coders," says administrator Tim Smith. "Physicians simply can't keep up with the information, with the necessary modifiers, and the bundling decisions from payer to payer. Even if the physician attends a once-a-year meeting on coding, that's not enough. Physicians who code by themselves and enter that information into the billing system will make lots of mistakes. However, we don't want coders coding without getting the surgeon's input. So we try to take a middle road and have both of them involved."

Technology to the rescue

"Physicians can do their own coding if they use the technology that is available to them," contends Whit Dunkle, a physician with HealthONE, the largest for-profit hospital corporation in Colorado. Before Dunkle had the tools and quick reference sheets he now uses, it took him over 40 minutes each day to code. Now, after seeing 20 patients on a given day, he can code in 10 minutes or less using coding software.

"If physicians are going to code, they must depend upon technology to help them code more accurately and quickly. I would never walk around carrying the coding book. This is a lot better than the book."

There was a time that Dunkle found coding onerous despite the fact that his office had a useful electronic coding tool in place. A few years back, his clinic was using a voice-activated transcription program to create the patient record. This system allowed for the creation of templates and macros to aid in improving documentation. Specific macros were developed to incorporate E&M guidelines. For example, if the physician said "shoulder strain," the program automatically put in the ICD-9 and verbal description.

Because he was doing most coding on his own - and was unsure how accurate he was -- Dunkle decided to put himself to the test. "Over a period of two weeks, 94 new and established patients were randomly selected for my study. Upon completion of an office visit the superbill was completed with the charges I felt were appropriate," he says.

Later, the patient record was dictated using the voice activated transcription system. The results of the study indicated that 50 percent of Dunkle's documentation was consistent with the level of charges he expected; 10 percent did not support the level of coding he expected; and 40 percent exceeded the charges he expected.

To improve the situation, Dunkle recently added a new software program to his laptop computer that allows him to compare the superbill he created with the level of service he is providing. "I'm a proponent of physicians doing coding with software because it makes their lives easier," he says. "Technology can also make coding more accurate, protect you legally, and ensure that you get paid the proper amount."

"Using technology is the future," agrees Laurie Wagner, president and CEO of MD-IT, a Denver-based provider of software solutions for physicians. "The concept of adding coders to the practice to get the work done won't improve the quality of the coding. Having physicians circle the superbill isn't coding, either. When technology is used as a tool and tied to the documentation, the coding will be correct, and physicians will get paid for the actual work they do."

Hire it out?

"There are certain specialties that lend themselves to using professional coders," says Marvel J. Hammer, president of MJH Consulting in Denver. They include "cardiology, orthopedics, and neurosurgery -- procedure-driven practices with complex procedure coding. For example, if spine surgery is done with reconstruction and instrumentation is involved, there may be a multitude of codes that are needed to accurately describe these services."

On the other hand, "reimbursement levels don't support family practice and primary-care physicians or pediatricians taking this step. These types of practices should consider hiring a professional coder to audit quarterly and teach their billing staff about coding," Hammer suggests.

Hammer recommends that physicians and professional coders take a team approach. A professional coder needs to practice effective communication with the physician in order to ask appropriate questions. Likewise, the physician will probably have one overriding question -- "Where is the cost benefit?" -- when deciding whether to hire a certified professional coder or to bring someone on periodically to audit.

According to Elizabeth Woodcock, director of knowledge management for Physicians Practice Inc., "Since coding is so complex, it's nearly impossible to do it as an afterthought." She adds that, "The documentation should be scrutinized for all applicable procedure and diagnosis codes, as well as to evaluate the applicability of modifiers. Often, a thorough review of the documentation leads to a complete coding of all services, versus the single procedure and single diagnosis code that may be attached if the coding process is rushed -- or simply not a priority."

"Right now, many seminar speakers are encouraging the physician to do his or her own coding," says Smith of Scott Orthopedic. "We do not agree with that. Yes, the physician needs to be involved because of his or her clinical expertise and that knowledge needs to be imputed into the process."

"Coding is an art ... it's not an exact science," says Hammer. "There isn't always one diagnosis code that can accurately describe what the diagnosis is, which is why coders are a great knowledge base for physicians to draw upon."

Vicki Gerson can be reached at

This article originally appeared in the January/February 2002 issue of Physicians Practice.