Seek Specialty Opportunities and Overcome Their Challenges

The benefits of taking on a new specialty are worth the initial extra legwork.

By Pam Brooks, CPC

The trend toward comprehensive patient care will create a demand for many new multi-specialty practices. As practices expand, the need for specialty coders will, too. But these jobs won’t come without challenges. Even experienced coders can become overwhelmed when learning a new medical specialty, with all the unfamiliar procedures, terminology, and payer guidelines. With a fair amount of organized and careful front-end prep work, coders can overcome the obstacles of learning a new specialty and reap the rewards.

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Review the Data and Do Your Homework

If your new medical specialist has recently worked in another practice setting or facility, you may be able to get a list of his or her coding activity over the past year. When a provider joins a new group, the accounting department usually has access to this historical data to determine the return on investment (ROI) they can expect based on past performance. This list can provide you with insight as to the kind of work your specialist will do at your site.

If possible, sort the list of CPT® codes from the most- to least-commonly performed procedures. This will give you an idea of the scope of the new provider’s practice, and where you’ll need to focus your efforts in terms of learning new coding guidelines. You should also review the list against the most up-to-date version of CPT® to make sure the codes are still current. Keep in mind, however, that any previous coding and billing should be viewed as “suspect.” That is not to say you should assume the provider was billing incorrectly or fraudulently; rather, only use this historical data as a guideline. After careful review, move forward. This will help to ensure your own correct coding.

It’s unlikely that diagnosis coding will be included in the financial data because physician coding and billing is not reimbursed based on diagnosis. It’s a good idea, however, to research the conditions and illnesses for the procedures you’ve identified and to learn about the related anatomy, pathophysiology, and typical treatment plans. Familiarizing yourself with common courses of treatment will enable you to recognize when your provider has gone over and above what is expected. If you come across unfamiliar terminology or concepts, look them up. This is an excellent way to learn about your new specialty or to refresh your memory.

Meet with Your Doctor

To better familiarize yourself with your new specialty, secure a time to meet with your new provider to learn about the types of services she provides. Ask if there are any videos or books you could review that would give you a visual perspective of her work. Alternatively, there are a fair amount of surgical procedures available on YouTube. Or, you can Google any of the procedures you are unfamiliar with.

To prevent billing errors, ask your provider what procedures she will perform in the office verses in an outpatient surgery or inpatient operating room setting.

If part of your responsibility is charge capture, you can also use this meeting to decide which services belong on an office fee ticket, and which services might need to be on billing cards or order sheets for work done in the facility setting. If your provider will be using an electronic health record to document her work, you can offer your expertise as a coder to become a part of the template development team by offering advice on documentation guidelines.

After you’ve gotten a pretty solid idea of your provider’s scope of practice and the procedures you can expect to see, start doing compliance research to support your correct coding. Access the Centers for Medicare & Medicaid Services (CMS) Physician Fee Schedule (PFS) to determine if any of the identified procedures or diagnostics will require you to bill globally or with modifier 26 Professional component. This is also where you can determine whether an assistant surgeon is allowed, what the global days are, and what the associated relative value units (RVUs) are.

Note: For more information about the Medicare Physician Fee Schedule (MPFS) database, see “Use the PFS RVF to Expand Your Coding Knowledge,” April 2011 Coding Edge, pages 42-44.

Know Specialty-specific Code Guidelines

To make sure you’ll recognize which codes cannot be bundled, run commonly-used codes through the National Correct Coding Initiative (NCCI) edits, and take the time to revisit the modifier lists and definitions to determine if any modifier use would be required in certain circumstances. You’ll want to make sure your chargemaster reports the appropriate fees associated with those modifiers that affect reimbursement, so you aren’t under- or overcharging.

If any unlisted codes show up as part of your new provider’s scope of practice, you will have to investigate the most appropriate comparable listed code. You should also review HCPCS Level II and Category III codes to make sure none of these are being overlooked regarding your new provider’s billable services, equipment, or new technology.

Visit the websites of both CMS and your local carrier to identify any national and local coverage determinations (LCD) related to the list of CPT® codes you’ve identified. It can be helpful to gather all of this information into either a notebook or on your desktop as a virtual procedures manual for later reference. Just remember to update it every year.

Expand Your References

Medicare isn’t your only payer, of course, so visit all of your payer websites or contact your provider representatives to learn if they have any specific coverage determinations based on your list of identified CPT® codes. Depending on your new specialty, some procedures or surgeries may be considered experimental, cosmetic, or non-covered, or require payer-specific modifiers or other billing guidelines.

Professional associations your providers are affiliated with are useful resources for finding this specialty-specific information. For example, American College of Obstetricians and Gynecologists (ACOG), Society of Thoracic Surgeons (STA), and American Association of Orthopedic Surgeons (AAOS) all have websites with valuable information for practice management and coding. Often, these resources provide specialty-specific coding and billing workshops, newsletters, or coding services that can help you navigate the ins and outs of your new specialty.

AAPC is also a significant resource for specialty coders. By logging onto the member forum, you can pose questions or search for previously asked questions in a number of specialty areas, with answers usually provided by senior coders who routinely provide links to regulatory guidance. Most importantly, you can obtain additional training and specialty certification through AAPC’s conferences, workshops, and specialty certification examinations.

Networking through your local AAPC chapter can help introduce you to coders who may have experience in your new specialty. You can also arrange to be on the mailing lists of neighboring local chapters, so if they are holding a meeting regarding your specific specialty, you can attend, learn, and network.

Learning a new coding specialty can be a fun and interesting challenge if you’re motivated and apply a systematic and careful approach to setting up your coding and billing protocols. You can also use this approach to prepare for a job interview in a new and exciting specialty. Take advantage of available resources to add value to your current employer and add experience to your resume.


Pam Brooks, CPC, is the physician services coding supervisor at Wentworth-Douglass Hospital in Dover, N.H. She holds a Bachelor of Science degree in Adult Education and Workplace Training from Granite State College, and is working on her master’s in Health Administration at St. Joseph’s College of Maine. She is a past secretary of the Seacoast-Dover N.H. AAPC local chapter.


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