Physician CPCs: From the Inside Out
Physicians reveal the recent trend for earning their credentials is about opening the lines of communication with coding and billing staff.
By Michelle Dick
Whether a physician coder is on a review board, teaches coding to other physicians, or owns a private practice, he or she will agree it’s advantageous to have coding credentials. Large practices with a team of expert coders find a coding credentialed physician valuable for communication between medical staff and coding staff; whereas small practices benefit because many lack experienced coders, which puts a physician at risk. Whatever the reason, one thing is certain: keeping up with current coding is essential. The following seven physician/coders talk about the certification process as well as their own experiences.
Peter R. Jensen, MD, CPC
Dr. Jensen graduated cum laude from the College of the Holy Cross with a degree in economics. He received his MD from Dartmouth Medical School. He completed his residency in internal medicine at the University of Florida at Jacksonville and his nephrology fellowship at MUSC in Charleston, S.C. Dr. Jensen is board certified in internal medicine and nephrology and is a partner in Gulf Coast Kidney Associates in Sarasota, Fla. He is also an assistant professor of clinical medicine at the Florida State University College of Medicine. In addition to being a practicing physician, Dr. Jensen is a Certified Professional Coder and physician reimbursement consultant. He founded E/M University (www.emuniversity.com) located in Sarasota, Fla.
To obtain certification, Dr. Jensen took an online course and signed up for the certification exam. He admits the test was more challenging than expected. “At first I thought I was going to cruise right through, but in the end I barely finished on time,” says Dr. Jensen. He earns CEUs from his speaking engagements and through his own website. Coders can get 10 free CEUs for reviewing his library of E/M coding courses. “My job is to help coders translate the E/M guidelines into the clinical language doctors can understand, so if you want to reach the doctors, you have to go through the coders,” says Dr. Jensen.
Coding credentials change the way coders look at Dr. Jensen. He has credibility when he talks about the specifics of coding, and it changes the way he conducts business. He now codes his services 100 percent of the time. As for the way other physicians look at him, whenever he brings up coding in the physicians lounge, they all stop talking and sit back down. “Doctors are reluctant to talk about money and reimbursement, but everybody is afraid of getting audited. E/M compliance is a hot issue right now,” says Dr. Jensen.
“It’s easy to be a good coder without being a good doctor,” Dr. Jensen says, “but nowadays it’s hard to be a good doctor without being a good coder.” He feels that doctors who don’t understand the rules tend to over-document their encounters, which means more time spent on paperwork and less time spent with patients. It’s a very important part of what they do and he advises other physicians to get coding credentials. Dr. Jensen’s motto is “I put the ‘Doc’ in documentation.”
Andrew K. Worthington, MD, CPC
Dr. Worthington is a board certified neurologist. He attended medical school at Virginia Commonwealth University School of Medicine (MCV), Richmond, Va. and completed his neurology residency at Barnes/Jewish Hospital Washington University, St. Louis, Mo. He left private practice after 16 years in 2003. Now, he devotes his time to E/M coding from a practitioner’s point of view as CEO of Code Blue Coding (www.codebluecoding.com).
To prepare for the certification exam, Dr. Worthington started (but never finished) a home study course. He also relied on his knowledge of medical terminology, and admits he doesn’t know how anyone can pass the exam without prior medical knowledge.
Being a certified coder changed the way Dr. Worthington viewed coding. Before he was a coder, he didn’t understand that in order for the medical profession to expand and become up-to-date with banking and computer technology, it needed its own language to automate the industry. Basically, he realized medical coding is the transformation of handwritten paper billing to billing that can be entered into a computer system. He found many physicians don’t understand the CPT® system or what it is, why it’s here, what it does, or why they have to deal with it. He discovered that health care couldn’t have grown to what it is today without the CPT® system.
Dr. Worthington does his own auditing in E/M coding, but once he gets outside of that distinct area, he out sources. He recommends that more physicians get their coding credentials. He claims there is a move toward physicians banding together in larger groups such as in employment networks that purchase practices and hire physicians. In these networks, physicians have no idea of what coding is. He thinks it is in the practice’s best interest to pick physicians out of the groups and pay them extra to obtain coding certification. This would allow them to turn to their peers and share with them their knowledge.
When talking about his specialty, Dr. Worthington says, “My specialty is E/M coding … The more I listened to coders talk to physicians, I recognized in just this one little area of coding there was a significant disconnect between the coders and the physicians … I wondered why that was … It didn’t seem to be present in other areas. When coders were talking to orthopedic doctors about operative procedures, I didn’t notice a big a gap. After looking at the E/M guidelines and rules for quite some time … it became obvious to me that the entire E/M system was originally built and designed around medical decision-making … It has fallen to coders to teach that system to physicians” to provide an understanding of how it works. “It is very difficult to teach this system to physicians without having learned and practiced medical-decision making.”
“I don’t have to tell coders that doctors are a tough audience,” Dr. Worthington adds, but “the need for certified physicians as ambassadors/translators/bridges between the physician world and the insurance /hospital/coding world is pressing and becomes more so daily.”
Joel Grossman, MD, CPC
Dr. Grossman started his career practicing general and hospital psychiatry. Due to a condition of ulcerative colitis in 1983 and 1984, he was hospitalized for long periods of time, which forced him to stop practicing in 1984. He returned to work as the utilization review coordinator for the hospital at which he had been practicing. In 1986, he formed South Florida Utilization Review (SFUR), where he is president, a certified medical audit specialist, and a certified professional coder.
At one point in his career, he was asked to look at bills, but did not know anything about coding. Self-taught along the way, he extracted the correct codes from operative reports and reported back to the client. He became the anointed coding expert as the client didn’t have the coding capabilities to do this task. In 2004, he decided to obtain his coding credentials through AAPC to make it official. The same year, he became a certified American audit specialist. Dr. Grossman continues to receive many workers compensation surgical and other bills, the majority of which involve CPT® orthopaedic codes. Presently, Dr. Grossman serves as a member of the American Medical Association CPT® Advisory Committee representing the American College of Medical Quality.
He finds that reviewing coding cases, especially operative reports, is like solving a puzzle, each one unique in its own way. He receives letters from doctors appealing the claim determination, and found that having the CPC credentials allows him to respond with credibility. The credentials enhanced his coding ability, and familiarized him as well with ICD-9-CM and HCPCS Level II codes.
To prepare for the exam, he bought a study manual. It was not helpful with orthopedic or E/M codes, which he already knew, but it was helpful with all the other procedural codes and those with which he was not familiar, such as vascular codes.
Dr. Grossman says, “If a doctor is interested in getting a CPC credential, he or she shouldn’t hesitate. Doctors already have a tremendous advantage due to their stored knowledge of anatomy. The test would not be as difficult as for someone else. Many surgeons do code their own operative reports, but the majority leave that key link in obtaining reimbursement to an office person with little or no coding background. Especially in a group practice, that doctor who is the group administrator should be a certified coder, too.
“The source of income for doctors is their services, and as services are translated into codes, and codes are translated into dollar reimbursement, a knowledge of coding is the final piece to one’s medical economic education in guaranteeing correct payment.”
Davis, MD, CPC
Dr. Davis is a graduate of Temple University Medical School class of 1989, board certified family practitioner, and trained at the University of Wisconsin. She began her career in rural family medicine with obstetrics in Wisconsin. Today she is chief medical officer for Medical Card System, Inc. of Puerto Rico. She worked for Wellmark, Blue Cross Blue Shield, Inc. for eight years prior to accepting her current position.
Dr. Davis’ motivation toward obtaining coding credentials became apparent when, “I worked a lot with codes and I understood the clinical significance. I understood what the code itself was trying to say, but I didn’t have an appreciation for what I call the ‘grammar’ of coding … When you write a sentence, there is a way you structure that sentence. There are rules to how the sentence gets structured, so people understand what you’re saying. I didn’t have that piece. It became abundantly clear to me that I needed to know the ‘rules’ about coding as well as the content of the codes themselves,” says Dr. Davis. That’s what led Dr. Davis down the path.
Although the certification test made Dr. Davis nervous, she felt it was relatively easy as she was familiar with the codes themselves. Her main focus was on studying the rules. Because of her background and training, she didn’t need orientation to medical terminology, anatomy, or physiology.
Dr. Davis obtains her CEUs through American Academy of Family Physician’s (AAFP) Family Practice Management monthly coding literature, and through the AAPC’s Coding Edge magazine. She also researches codes to communicate with medical providers when there is a dispute about the coding of certain services. In other words she uses “real work” to earn CEUs. Another way she earns CEUs is by attending CPT® conferences that the AMA puts on to keep current on what is changing the next year.
Dr. Davis never did her own coding; however, she has a deep appreciation at end of the day for those she relied on to translate it into a billable document. She “absolutely” recommends getting credentialed, unless the physician works for a very large organization (for example, a physician with a good compliance department). Dr. Davis says, “Not understanding coding puts you at risk. If you don’t understand the rules, even if you are making innocent mistakes, Medicare and other auditors can come knocking on your door if you haven’t followed the rules, and haven’t coded appropriately. I think it’s important for every physician to have a basic understanding of coding and the codes they use. Some physicians invest in others to do that for them. Ultimately, if it’s a physician’s business, he/she is responsible for what he/she is billed. Now that I know that, I would never take the risk again of not being actively involved in my own coding.”
Michael Shapiro, MD, CPC, FAAEM, FACEP
Dr. Shapiro has been involved in medical practice management and billing for about 18 years. He was appointed as Brevard’s Emergency Services’ managing partner about nine years ago to supervise the group’s billing and coding office. The practice consists of about 30 ER physicians and hospitalists.
Being a certified coder changes the way Dr. Shapiro does business. It provides a lot of credibility when dealing with other medical businesses, hospitals and insurers, and it instills confidence when discussing coding issues. He uses his coding knowledge for improving documentation, speaking engagements, consulting, writing, and business administration. With his coding knowledge and credentials, he can argue effectively and persuasively with insurers. His medical and coding cross-training helps him to educate his own coders about the medical procedures they are coding and also helps him when talking to physicians about their documentation.
Dr. Shapiro does his own coding primarily when auditing records in his own practice. He recommends that physicians in a management role like him get their coding credentials. As for most physicians who practice clinically, Dr. Shapiro says full certification isn’t necessary. However, he says “some knowledge of documentation requirements and coding rules is essential for physicians who want to optimize the reimbursement for the work that they do.” He suggests that coming up with specialty-specific certifications for physicians might be a good idea, and he is currently working to develop training courses for this purpose.
Alan F. Strobel, MD, CPC, CHC
Dr. Strobel is currently at North American Partners in Anesthesia (NAPA) (www.NAPAanesthesia.com) the nation’s largest private practice anesthesia group, with more than 300 physicians and 125 CRNAs. NAPA provides anesthesia services for 18 hospitals in Maryland, New Hampshire, New York, and Pennsylvania. Dr. Strobel uses his coding knowledge for NAPA’s Practice Management and Billing Organization, known as NAPA Management Services Corporation (NMSC) — a management services organization that provides practice management and billing services to Allied Pediatrics of New York and North American Partners in Pain Management. Dr Strobel is also the director of obstetrical anesthesiology as well as the director of healthcare compliance at NAPA.
Dr. Strobel says the certification test is extremely thorough and difficult. The complexity reminded him of some sections on the Medical Board Exam. While the anatomy was second nature to him, the principles of coding had to be learned over three months of independent study. It was a learning experience about non-anesthesia billing and provided him with a familiarity of non-anesthesia disciplines and initiatives. He obtains his CEUs by attending lectures that pertain to his job description.
Being a certified coder has helped him communicate effectively among the company’s CPCs and comprehend everything explained to him by them. He can now relate the coding information to NMSC’s medical staff, sometimes in the form of policy, which streamlines the billing and compliance operation.
Dr. Strobel does his own coding and would recommend others physicians do the same. He reviews the billing daily for all anesthesia procedures provided by NAPA from six hospital locations. He audits the remaining 12 locations along with their VP Compliance, Bill Clark. Dr. Strobel says his credentials position him to audit, modify, institute policy, and appreciate all the billing staff does for their organization.
Thomas Proctor, MD, CPC
Dr. Proctor is currently a board member of the Emergency Management Organization and devotes his time to Prestige Billing Services, which focuses on all aspects of reimbursement and claims management.
Dr. Proctor’s role with his billing company originally involved communication with the coding staff to clarify physician documentation and medical principles to minimize interpretation errors. In turn, he educated the physicians on documentation principles and medical record pitfalls that had a negative impact on reimbursement. He immediately realized how important this ongoing dialogue was for the mutual success of the two entities, and to maximize coding compliance and accuracy. When referring to the certification exam, Dr. Proctor says, “I prepared for the exam by familiarizing myself with the organization of the CPT®, ICD-9, and HCPCS books — no easy task! My coders gave me a copy of a practice test with sample questions for self-assessment of my progress. The exam was long, but I finished in the allotted time with only minutes to spare. I thought the exam was fair, represented an appropriate spectrum of areas of understanding, and was well written. Clearly, a physician has the advantage in preparation and execution of the test because we already speak the medical language, but the exam was daunting nonetheless.”
To obtain CEUs, he attends biannual conferences sponsored by Emergency Management Organization, an Ohio-based coding organization focused in emergency medicine, his area of practice. He also reviews articles in Coding Edge. Having obtained certification was very important to his relationship with the coders. He believes they feel he understands how challenging their work can be, and how crucial their role is in the success of his business. Malpractice risks are reduced while maximizing their reimbursement in areas where charting was remiss allows appropriate billing for the services performed.
“Physicians are notoriously inaccurate at doing their own coding,” says Dr. Proctor, “so I do not do my own coding or promote that practice to other physician groups. At the time of service, we tend to minimize the work we do because it is ‘routine’ to our practice, when the reality is that we provide a significant cognitive service that is best converted to an appropriate E/M level by trained coders. That said, if the bottom fell out of our coding company, I feel I could step up and provide some assistance … but much less efficiently than (coders) do!”
“I am not an advocate for every physician to obtain coding certification,” Dr. Proctor stresses, “but I do think that there is tremendous benefit in a medical group having a physician who facilitates conversations between care providers and the coding staff. It is imperative to have that physician understand coding principles, and promoting this professionalism through certification provides motivation and merit to this dialogue.”
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