Coding: Why It’s NOT Just the Biller’s Job

Coding: Why It’s NOT Just the Biller’s Job

A lot of my colleagues tell me they don’t want to get involved in coding. They have all kinds of reasons why they don’t think it matters.  It’s too complex, their billing staff has it covered, or it doesn’t really make a difference who does it.  All of these excuses make me want to pull my hair out!  Coding does matter.


Great coding is the cornerstone of a profitable practice! The ONLY way you can tell me that coding doesn’t matter is if you are independently wealthy and don’t need your paycheck. Even then I would argue, make the insurance companies recognize your value and donate the money to those who do need it!  Clean coding means your claims are less likely to fail and you are going to get paid more quickly. Don’t tell me it’s too difficult. Organic chemistry and immunology and the hypothalamic-adrenal-pituitary axis are difficult. Coding…not that hard.


Here’s the biggest problem you will have when you put all of your coding in the hands of your billers. They were not inside the exam room nor inside your head during the patient visit. CPT coding levels are based on history, ROS, and exam elements. They don’t know that you checked skin turgor. If you don’t write it in a note, it wasn’t documented for them to see. From their standpoint (and the insurance company auditors) it wasn’t done and they can’t bill for it. Sometimes skin turgor documentation is all you need to move from a level 99213 to a 99214 (in the appropriate scenario.) You can’t tell me that you didn’t touch the patient’s skin while you were looking for a rash and subconsciously or consciously note the skin turgor. Did you ask if the child is in daycare? That’s social history! That counts! If you don’t document that you reviewed social history, no one can assume you did.


Here’s the critical coding principle: complexity of medical decision making is integral to CPT coding. There is no way your biller knows what you were thinking when you put down URI as the diagnosis for the 8 month old you saw yesterday. Did you think to yourself, “this kiddie doesn’t have signs of meningitis, doesn’t look like a serious bacterial infection, doesn’t look like bacteremia. His immunizations are up to date, so I am less worried about invasive pneumococcal and HIB disease. While his temp is 101, I know he attends daycare, his 3 year old sister had a cold last week, and I reviewed his problem list and neonatal history so I know he was full term and healthy.”


I’m guessing most of the above was true, but your biller won’t know that if you don’t write it down. If you think that the proper coding is a 99213 and didn’t require more complex medical decision making than the 11 year old with a URI and a temp of 101, you are without a doubt undervaluing your education and experience. (Important note: I would still summarize my medical decision making by writing “no signs of serious bacterial infection, no lower airway involvement and no concerns about invasive disease.” At least when insurers review that, they have a “glimpse” into what you were thinking and your differential diagnosis.)


How often does a simple visit get hijacked by a 25 minute discussion about behavioral concerns? The biller wasn’t in the room to know it was part of the exam and they don’t know how much time you spent face to face speaking with the parents or the patient. You have to document how much time you spent and code according to time guidelines when appropriate.


Value your expertise, your time with the patient, your ability to solve complex problems. Then code appropriately so you are paid appropriately. If you are uncomfortable, attend a coding seminar, subscribe to AAP coding resources, or find someone to help you. Many practices can increase their profitability substantially just by being informed and having physicians take ownership of their coding practices. Your involvement makes a BIG difference.

Tags:
, ,