ACC: How to avoid cath lab billing & coding 'ruts'

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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:

Chief complaints:
“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.

Patient complaints:
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 to Gates-Striby.

Review Systems:
In cardiology, seven or eight review systems are common; however, to bill on the comprehensive level, you will need 10. “This causes a problem,” she said. When facilities write “for review of systems please see HPI as above. Often you think there is more information up there then there really is. I would caution you on this.”

Visit procedure dates:
“This is a big problem,” she explained. “If you are going to bill for a visit the same day as a procedure than that visit should be where you made the decision to perform the procedure or be about a condition that is completely unrelated and significant.” For example, billing for hyperlipidemia in a patient with whom you are performing cath wouldn’t be significant if you are simply refilling their prescription. These visits must include separate identifiable procedures and “not just have another diagnosis code.”

Additionally Gates-Striby offered that physicians should:
  • Avoid abusing the phrase, “poor historian/unreliable” if unable to obtain patient background and history;
  • Get in the habit of listing five systems minimum to offer "good patient care";
  • Protect yourself by personally examining and documenting your own patient exam findings. “Don’t just co-sign a note.” If a coder or biller feels that a physician’s contribution to the exam was insignificant, the case will be down coded; and
  • Avoid writing “agree with above” frequently, as it will result in refunds. 

Cath lab specific coding: What to look out for:
Often the coding process can be difficult because most coders have never come in contact with medical terminology or anatomy. “Don’t expect them to completely understand all of this,” said Gates-Striby. Discrepancies of communication between cardiologists, coders and billers can create a faltered system. She suggested that physicians and coders have more contact, and that physicians  invite coders to spend a day in the cath lab to help instill this partnership.

Additionally, Gates-Striby offered the following cath lab related tips to get over the coding hump:
  • Closure devices: You cannot bill for using a closure device or the opening you’ve created, said Gates-Striby. “If you created the opening you, have to close it, that’s just the way it works.”
  • Programming evaluations: You do not need to reprogram a device to have performed a reprogramming evaluation;
  • Confusing coding: Physicians should be aware of problematic coding such as coding for venous sinus, which refer to sinuses in the head and not the coronary.
  • Using specificity: It is important to use key words and avoid using words such as “to” and “into” which can misconstrue data. “If you say a catheter was advanced to the superficial femoral artery (SFA), you are not in the SFA,” said Gates-Striby. This can change meaning and result in a shift from a third to a second order. Using words such as “was engaged” or “selectively placed” could alleviate this coding misrepresentation; and
  • “Don’t assume you’ve found a great loophole:” If you think that you have found some additional codes to bill that no one else is billing, “chances are you’re not a genius in coding, you’re just about to make a mistake,” she said.

By creating better communication, reading and accepting feedback from coders and billers and working to avoid coding and documentation mistakes, you can help to gain better facility-wide reimbursements and avoid mistakes.