It’s a Good Time to Be Certified
As the physician role evolves, professional coders become more important than ever to reimbursement.
By Sylvia Adamcik, CPC, CPC-I, CCS-P
At my age, I know how much the physician office visit has changed over the years, and I have a pretty good idea of what it will be like in the future.
A Simpler Time for Physicians and Patients
As a small girl in West Texas, we had a family doctor who took care of the entire family. He delivered the babies, doctored them into adulthood, and provided elder care and end of life care. He did it all. The staff generally was one nurse and sometimes a receptionist. Many times the nurse was the part-time receptionist. The doctor made house calls when a patient was too sick to come to the practice—and that included weekends and holidays.
I remember our family doctor coming to our house early on a Sunday morning to take care of me when I had a bad kidney infection that manifested overnight. He came in his hunting clothes, with his bird dogs in the Jeep. (It was pheasant season and he had been out of town at his family’s farm, hunting.) He diagnosed me, gave me an antibiotic injection from his medical bag, and wrote a prescription for oral medication. My mother filled it at the one drugstore open on Sunday for a few hours. By noon, I was in much less pain and feeling hungry. I don’t know how much he charged for this home visit, but I know that in those days a visit was just that and there was usually one fee applied, no matter what the circumstance. No one had heard of health insurance. What a huge difference from today’s physician practice.
Modern Health Care Is Complex
Now, house calls are rare almost to the point of extinction, and appointments with the family physician are made days, weeks, even months in advance. If an emergency occurs on a weekend, you go to an urgent care clinic or the emergency department (ED) of the local hospital, depending on the severity of the illness. When assessment and treatment is complete, you’re told to follow up with your personal physician or a specialist, depending on the condition.
When a patient has an appointment with the family physician, a staff member calls the patient and/or insurance company just prior to the visit to verify coverage, if there is a deductible and if it has been met, and what the co-pay amount will be. When a patient enters the reception area, he or she is:
- Greeted with patient registration forms to be updated.
- Handed Health Insurance Portability and Accountability Act (HIPAA) forms to be read over and attested to.
- Asked to present their health insurance card so a copy can be made.
- In some cases, asked to show a driver’s license or some other form of photo ID to verify identity, and
- Possibly asked for prepayment of a copay, if applicable.
EHRs are Changing Health Care
The electronic health record (EHR) system is used to register the patient and notify the nurse/clinician that the patient is in the waiting area. When the patient is called back, the EHR tracking system is activated. Many EHR systems have tracking capabilities to show which room the patient is in, what time they were put in the room, and what time the visit ended. During the encounter with the nurse, nurse practitioner (NP), physician, or other provider the patient’s history, examination, and the provider’s assessment and plan are entered into the EHR. No more scribbling on a paper chart with illegible handwriting. No more one fee per visit. Each separately billable service is documented so it can be reviewed, coded, billed, and reimbursed as allowed by the patient’s health insurance plan.
Doctor Diagnosis Needs Verification
The process of diagnosing patients also has greatly changed. Taking vitals, the hands-on examination, and questioning the patient are all still part of the diagnosing process, but our litigious society dictates that a provider does not risk using just his or her diagnostic skills and training alone. Now, laboratory tests, radiology exams, and other diagnostics are required to confirm that the provider’s evaluation of the illness or condition is correct.
What This Means for Coders
When I was a child, there were no procedure, supply, or diagnosis codes to be sent to an insurance company for reimbursement. The doctor provided a service and the patient paid for the service as best as he or she could, either at the time of service or later when the bill came—in installments, perhaps. If a patient did not have the resources to pay, the provider took care of them anyway. Communities pulled together, and physicians shared in the responsibility of taking care of those who were less fortunate.
Today, we have governmental and private programs to give assistance. These programs, like private health insurance plans, require rendered services to be correctly coded and submitted in a timely manner for payment of those services. Submitting services with ICD-9-CM and CPT® codes not only is the source of revenue for providers, it is the source of tracking and trending diseases and conditions in the United States and the rest of the world. For more than 40 years, we have seen the evolution of CPT® and ICD-9-CM codes as medicine and health care have evolved with new illnesses, procedures, and techniques.
Coding Will Factor Into Physicians’ Success
Looking ahead, the physician practice will continue to evolve as it transitions to ICD-10, EHRs become mainstream, and the government gets more involved in socialized medicine.
Coders are now, and will continue to be, the pivotal factor for any successful physician practice. In this age of managed care, contractual obligations, and governmental oversight, a physician practice cannot afford to miss any legitimate reimbursement opportunity. To maximize reimbursement, qualified, experienced, certified coding personnel are necessary to help steer the practice in the right direction during these new, unknown, and often very frightening waters.
As a professional coder for many years, I look forward to each new challenge and feel confident in knowing that our profession is growing in knowledge, expertise, and recognition. It’s good to be a coder in today’s health care world!
Sylvia Adamcik, CPC, CPC-I, CCS-P, is unit manager for the Medical Practice Income Plan for Texas Tech University School of Medicine with over 25 years of experience in health care. She is a member of her local AAPC chapter, currently serving a as president, and was named a 2009 Region V finalist for Coder of the Year.