Coding and documentation is often the chink in a facility’s armour. Issues such as improper documentation, overcoding and a lack of communication between coders and physicians can often steer facilities into “a coding rut,” said Linda Gates-Striby, CCS-P, ACS-CA, compliance manager at the Care Group in Indianapolis, during a presentation Tuesday at the American College of Cardiology (ACC) scientific sessions.
Gates-Striby, who reviews coding and billing at cardiology practices, offered methods to smooth out the lapses within the coding and billing process. Facilities “need a coding champion” who is willing to act as the go between linking the billing and physician staff, she said.
The first step in identifying whether you are in a coding rut is to compare your individual evaluation and management coding levels (E &M) to others in your practice, Gates-Striby explained.
When performing reviews of coding and compliance, Gates-Striby said that she often sees huge differentiations in a facility's billing and coding systems. According to Gates-Striby, one way to alleviate record requests and audits is to ask the billing staff to share information twice a month so that individual cardiologists can compare their own coding patterns to expectations set forth by Medicare.
“When you get too far off of that expectation, that’s when the record request comes…that’s when the audits come,” she explained. “What you want to know as a personal provider is what your score looks like, as well as your practice's score.”
Gates-Striby said that learning the reimbursement process “boils down to 12 definitions,” and knowing and understanding them could help increase reimbursements by 50 percent if you code at level four rather than level three. "Don’t be afraid to learn the definitions and code them appropriately for what you do.”
Facilities must look at hospital reimbursements, learn the definitions, use them and code appropriately, she said.
Gates-Striby cautioned, however, that physicians should never look at their numbers individually and think "'I am an undercoder', because you might also be an under-documenter.” During reviews she has often found that physician documentation did not support anything higher than what they were billing and this was due to lapses in documentation.
She noted that physicians should not make changes to the billing process until they review their documentation notes and receive feedback from the billing office on how they are doing.
“Get that feedback for yourself because whether you realize it or not your odds of being audited are pretty much 100 percent,” she said. “You don’t have to do anything wrong to be audited; it’s just part of the regular coding and billing processes,” she explained.
Getting a handle on coding; what you can do
Gates-Stiby offered several factors that physicians must take into consideration to accurately code and document:
“We need a chief complaint for billing,” said Gates-Striby. Often times rather than naming a specific condition during documentation of a patient follow-up, a physician will write “here for cardiology problem.” This hinders the billing process.
Rather than documenting history present illness (HPI), which includes a patient's history, timing and duration, describing these aspects in at least four different ways can help. Submitting one full complaint sentence, combined with four factors--such as 'relieved by,' 'associated with,' etc.--can help to fulfill HPI requirements.
If a patient presents without complaints, physicians should still mention at least two to three systems--‘their stable,’ ‘functioning well’ as well as document daily activity levels. Gates-Striby said that documenting patient complaints is one of the major problems within the system because the coding system is "very complaint driven."
Past patient history:
“Past history does nothing towards HPI and review of systems; we want to know ‘what about today?'," said Gates-Striby. Her “single biggest suggestion” is documenting new patient risk factors, rather than family history. Physicians should get into the habit of listing one risk-comment on the patient's past, one on a patient's family and one relating to social activity. This will allow physicians to pick up information within a patients social or family history that they may have otherwise missed. Listing these risk factors can ensure that you will be billed on the comprehensive level, according