You need to know how to accurately code, but getting paid involves teeth and grit as well as following the rulebook.
Never let it be said that I don't work hard for you, dear readers. In my tireless efforts to master and share information with you, I went so far recently as to attend a weeklong "coding boot camp."
There were no one-handed push-ups or bug-eyed drill sergeants, but the 10-hour-a-day forced march through CPT, ICD-9, and HCPCS was brutal indeed.
Here are some truths gathered in the battle:
Coding is not billing -- Knowing how to code according to the CPT rules is a good skill, but may have absolutely no correlation to your ability to get paid for services rendered. CPT coding is academics; billing is a street fight.
In class, for example, we learned all about the -25 modifier that theoretically lets you get paid for performing a procedure and a "significant, separately identifiable" E&M service during the same appointment. In other words, you could get paid for removing a lesion you noticed during a well-woman exam. That is all well and good in theory, but in practice you can pretty much count on any claim using the -25 modifier being denied or bundled at least once regardless of what the CPT rules say. Coding has to be accurate for you to have any chance of getting paid correctly, but accurate coding does not guarantee accurate payment.
At www.PhysiciansPractice.com, we get about 175 coding questions each month through our popular Ask an Expert function, which allows you to get answers to your management questions. Most users think denials reflect a coding error. Maybe so, maybe not. You could code correctly according to CPT yet still be peppered with denials when a payer's electronic claims review process kicks back something -- anything -- unusual.
In short, you need to know how to accurately code, but getting paid involves teeth and grit as well as following the rulebook. Know CPT and the rules your payers follow and appeal, appeal, appeal. The squeaky wheel gets the grease, not the most perfect wheel.
Trust no charge ticket -- As senior editor of a magazine, I don't really need to know the ins and outs of coding. I don't do it regularly, and none of my physician readers count on my personal knowledge of CPT. So I expected my classmates -- most of whom were billers, some with many years of experience -- to be far more knowledgeable on the subject than I. Turns out, many of them weren't. They bill by pulling a code off a charge ticket someone created three years ago.
Make sure your charge ticket is updated every year. Make sure your billers -- or at least someone in your practice -- know something about CPT and ICD-9. Pay for staff education if need be.
If you've been ignoring your coding for a while, invest in having an expert visit your practice and audit your charts. You may be surprised to see where you are under-coding or entirely missing codes you could be billing for.
E&M shortcuts aren't -- Evaluation and management visits are the fundamental services provided by many physicians. Take the time to learn to code the correct level of service, if you don't know already. I've heard about lots of shortcuts -- you can always just code by time; the more diagnoses, the higher the level; any visit that leads to surgery is automatically a level four.
Wrong, wrong, and wrong. E&M coding is based on the breadth and depth of the history and exam and the complexity of the medical decision-making. Yes, I realize that E&M coding is a needlessly complex way to bill, but if you refuse to figure it out just because it's stupid, you are probably losing money to undercoding. This is not the way to beat the system. If you are going to bill payers using CPT, know what you are doing.
There is no doubt that physicians' lives would be better with a more streamlined way to bill. Until that glory day comes, however, educate yourself and your staff about the limits and power of coding.
This article originally appeared in the September 2004 issue of Physicians Practice.