Coding: bane of your existence or key to your success?
Episode 13: Coding: Bane of Your Existence, or Key to Your Success?
First of all, improving coding is a must. I can hear your deep sigh… so many coding seminars… so many rules to remember… so much BS! Yes, it is. And, it’s how you get paid, and it’s made deliberately complex and onerous by the insurance companies in hopes that you’ll leave money on the table. Remember, they’re playing a different game! Instead of doing that, let’s figure it out and win the game! Studies show that approximately 80% of visits are under-coded. 80%! That means that 80% of the time, you’re giving the insurance company a big discount instead of getting paid fully for what you’ve done for your patients. Let’s not do that anymore. Let’s fix that!
To break that down, if you are under-coding office visits, let’s assume that instead of a 99214 (which was the level of service you delivered), you coded a 99213 (which is presently valued at 0.97 RVU’s LESS than a 99214), either because you didn’t document everything, or because in the back of your mind, you were worried about a coding audit, or because you delegated to a coder, and he or she reduced it to a 99213 without asking you any questions about it. In most markets, that difference is worth about $52. Let’s imagine you give the insurance companies $52 every time you see a patient. Let’s imagine you see 80 patients a week. That’s $4,160 a week or $216,320 per year that you’re giving the insurance companies! I’d like YOU to get that money instead, because you provided a 99214 level of service to your patients.
How can you improve your coding? If you are doing your own coding, I strongly suggest that you have a coding review.
I’d like to pause for a moment to talk about the rise in the use of Certified Professional Coders, or CPCs, and the depressive effect I see them having on many practices’ revenue. Many groups make the assumption that they have to use coders, which is not the case – there is no requirement. A lot of groups use them to reduce risk, and to assist with picking the correct code. While this is great, my observation of many coders is that their training and focus is all around compliance, and their goal is to mitigate 100% of business risk. This means they will always pick a lower code if there is a question between two codes. If your coders sit in a back room (or these days at home, working remotely), and just look at your chart notes and assign a code without any further input from you, they will typically always down code a visit if the documentation doesn’t support it. That’s what they’re trained to do. If you haven’t created a feedback loop with them, that claim will go out at the lower code, and you will have missed the opportunity to fill in the blanks on your documentation, and thus get paid for what you actually did. This approach will cost you hundreds of thousands of dollars. AND, you’ve got the added expense of paying them to have a depressive effect on your income. Not a good situation.
Creating a partnership with your coders will make the whole system hum. Be sure you’ve got good feedback loops, and look for coders who are appropriately detailed and somewhat aggressive on checking your documentation, and coaching you on what level is supported by your current documentation, and what could help get it up to the next level of coding with another bullet point or two. At the beginning of 2021, we got the benefit of coding for time spent, so be sure you understand those changes, and that you have text shortcuts or quick text in your EMR to insert the time spent with the patient into your note. That move will make you hundreds of thousands of dollars.
Again, vet your CPC carefully – you want one whose attitude is to go to bat for you, NOT to avoid an audit at all costs. If you’re coding and documenting correctly, the documentation will support the code. Your hard work will be “right coded” and you can rest assured that you will prevail in the unlikely event of an audit.
I should note that there is a lot of folklore out there about Medicare audits and this is out in the public realm, which perpetuates the fear of coding audits. In doing research, I was not able to find any published statistics on the percentage of clinics that experience a full-blown Medicare audit, but my educated guess is that it’s very low. In thirty years, I’ve known of only one clinic personally that went through one, and it was in relation to a larger DOJ investigation.
As an anecdote, our group was also involved with a client who had a business manager who committed fraud, and up-coded ALL visits to a level 5 for the whole family practice group of 8 providers for two years. This resulted in many hundreds of thousands of dollars in fraudulent billing. When our team found it, we worked with an attorney to help the clinic owners self report to the state, as many of their patients were covered by Medicaid. The state reviewed the case and decided not to prosecute, or seek return of the funds. I share this as one example of severe over-coding, and while we could not expect every case to turn out that way, perhaps that helps put the risk of over-coding into perspective.
My general sense is that with any physician doing his or her own coding, you’re likely to have some visits that are over-coded and some that are under-coded. In the unlikely event of a coding audit, it’ll probably come out in the wash. As a business owner, it is up to you to determine how much risk you are comfortable with. We’ll talk more about business risk and mitigating it in an upcoming episode. For now, understand that while it is possible to mitigate 100% of business risk, that is very expensive and likely to put you out of business. Managing business risk to a reasonable level should be the goal, and “reasonable” is different for every business owner. Managing risk of over-coding is exactly the same. Your goal should not be to get it perfect, or to mitigate all risk by under-coding every visit, rather to get it “close enough” that you can sleep at night.
To educate yourself and to open up more feedback loops with your coding team, your CPC or your revenue cycle manager should be able to produce coding distribution graphs for you. I recommend reviewing a distribution of new and established patient visits (99201-99205 and 99212-99215) for a month’s time. Compare that to another month out in the future once you’ve changed your coding or employed a CPC. We have coding distribution spreadsheet templates available for download on the Medical Money Matters Toolkit here, and if you’d like to see what those look like, you can find them in Chapter 2 of my book, Physician Heal Thy Financial Self, which is available on Amazon.
You can utilize those to see your coding distributions and compare them to others in your group.
In general, when looking at coding distributions, we see most providers’ coding graphs peak at a level 3, meaning they code the vast majority of established patient visits as a 99213. This may be appropriate, but if your practice has any type of complexity, like older patients, or a lot of patients with diabetes or other disease states, it may be more appropriate for your coding to peak at a level 4. We always want to be sure that your documentation supports your code, and as we heard in our last episode, we’ve seen many groups add medical scribes so that visits are being fully documented, and that their doctors are getting credit for all services that they’re providing to patients. This is key! You do a lot of work. You should get paid for all of it! That starts with writing it all down, which is where a medical scribe can be an invaluable resource. And, as the third part of the improving revenue series, we should explore how well your insurance contracts are paying.
Join me for our next episode, where we’ll talk about renegotiating your insurance contracts, to assure that you are getting paid well for the care you’re rendering to your patients.
