Coding Isn’t a Med School Requirement, but It Should Be

By Barbara Fontaine, CPC

I’ve worked with physicians for almost 30 years. Looking back, I remember thinking each time we added a new provider, “I wish I could have taught you what you need to know about coding while you were learning to be a doctor.” If medical students took a coding class while they were learning and practicing medical procedures, perhaps they would be able to see the vital connection between caring for their patients and coding for their services.

Living the Dream

Recently, I had the chance to live out my fantasy of teaching medical students about coding. I was invited to speak to students at the Saint Louis University School of Medicine. Approximately 35 students made up the audience, forming a new focus group of potential physicians who are interested in learning the financial side of their profession.

Evaluation and Management – CEMC

Doctors Wear Many Hats

I informed the students that they would be many things over their lifetime: a student, a resident, a doctor, a healer, a partner, a business person, and—most of all—a target. I opened their eyes when I explained that in the course of their career they would be reviewed, audited, and compared to peers by their patients, insurance carriers, and the government. The fact that the government has so many different agencies to monitor physicians really surprised the students. After explaining what the Centers for Medicare & Medicaid Services (CMS), recovery audit contractors (RACs), comprehensive error rate testing contractors (CERTs), and zone program integrity contractors (ZPICs) are, and how each department has a different focus, I told them that possibly the hardest lesson they’ll learn is what it takes to expertly document their services, and explained why it’s so important they make the effort.

Enter CPT®, ICD-9-CM, and HCPCS

My first task was to introduce them to the tools of our trade: CPT®, ICD-9-CM, and HCPCS Level II codebooks. I held up each of the books and asked if anyone was familiar with the publications. Only one hand was raised, and I wasn’t surprised that this student’s dad was a physician. I told the other students that CPT®, ICD-9-CM, and HCPCS Level II books would become as important to them as their textbooks are today, and that they contained everything necessary to report any service performed for their patients.

Meet Your Diagnosis Codes

I explained that ICD-9 is an older set of codes, having been established originally in 1893. When the International Classification of Diseases (ICD) originally came about, it was meant as a reporting tool for the World Health Organization (WHO) to track the spread of epidemics and other diseases, but in the United States, insurance carriers had adopted ICD for assigning medical necessity to procedures. Over time, the U.S. insurance industry completely changed the original intent of the book.

I told them that ICD-9 was adopted in this country for use on claim forms in 1979 and was mandated by the Health Insurance Portability and Accountability Act (HIPAA) in 2003. I also told them that the medical world is currently preparing for the biggest change in the history of health care as we gear up for ICD-10. By the time the students graduate, ICD-10 will be in full swing, and there will be nearly five times the number of diagnoses codes from which to choose.

The students now know that tied correctly to the procedure codes in Current Procedure Terminology (CPT®), diagnosis codes establish medical necessity for every procedure billed. I explained that correct coding accompanied by good documentation establishes medical necessity for what they do, and it will keep them safe in a world swarming with audits.

Meet Your Procedure Codes

Next, I discussed how CPT® was established in 1966 by the American Medical Association (AMA). The AMA owns the copyright on these codes, and updates them quarterly. Providing a standard set of codes, CPT® makes it possible to report and bill services in a common language. In other words, learning medical coding and billing is like learning a foreign language — a language in which all doctors should be proficient. We also talked about the Resource Based Relative Value Scale (RBRVS), which was developed to assign a monetary value to each CPT® code. I shared with them why it is important for providers of medical services to know how properly assigned codes will affect their income.

We concentrated on the CPT® section containing the evaluation and management (E/M) codes because these are the most frequently used codes. We talked about:

  • How it takes history, examination, and medical decision-making (MDM) to successfully document a patient visit;
  • The subtle differences between a new patient visit, a consultation, and an established patient visit; and how to carefully document to obtain the correct reimbursement;
  • How leaving out just one small fact or mistakenly reporting the location of a service can often change the level of a service drastically, and alter the reimbursement of a code; and
  • How these errors can cost a practice proper reimbursement or overcharges to the patient and the carrier.

The students seemed surprised that small documentation oversights can affect the bottom line of a practice.

Meet Your Supplies and Other Services Codes

Lastly, I explained that HCPCs Level II codes are used to report durable medical goods, drugs and biologics, supplies, orthotics, ambulance charges, and other medical services not defined in CPT®. Although HCPCS Level II codes are not used as often as CPT® in most practices, the codebook that contains them is still a necessary part of a good set of coding books.

More to Coding than the Medical Book Trilogy

I told the students that there are other sources billers and coders use to help establish a successful practice. Following close behind is the need for a good medical dictionary, anatomy books, terminology guides, and a great network of peers through listserves, workshops, and conferences, all of which will keep their valuable coders up-to-date with coding guidance, and keep them safe in a changing industry.

Mission Accomplished

Although it may never become a requirement of medical school curriculum, I hope these students will remember what they learned in my class, and it will help them in their careers.

I encourage other coders to look around for opportunities to make an impact on the lives of medical students. Look to nearby medical schools and consider how you might enlighten our future doctors with this essential information. Share what you know. Make a difference.

Barbara Fontaine, CPC, serves on the AAPCCA Board of Directors and is business office supervisor at Mid County Orthopaedic Surgery and Sports Medicine, a part of Signature Health Services. She served on several committees before becoming a local chapter officer. In 2008, she earned the St. Louis West, Mo. local chapter and AAPC’s Coder of the Year awards.


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