Increase Coding Transparency in Health Systems

New Processes and Communication Increase Efficiency at Facility Physician System

By Ann Bina, CPC, CPC-H, CPC-I
In the age of relative value units (RVUs), it is important for health care organizations’ coding departments to provide consistent and timely feedback to providers. At Gundersen Lutheran Health System, based in La Crosse, Wis., we’ve created an electronic feedback system that increases transparency with minimal work.

Make a Case for Change

Gundersen Lutheran has work processes similar to many other large health systems in the country. With more than 430 physicians and 250 associate staff in a health system spanning 19 counties in western Wisconsin, northeastern Iowa, and southeastern Minnesota, it’s not possible for our coders to be in the physician offices. Instead, the medical coding specialists in our patient business services department work in one central location—a set-up that is not ideal for providing timely feedback to providers.
In recent years, more and more physicians began asking for information regarding their documentation and coding. With increased scrutiny related to RVUs, physicians were interested in the codes that were assigned to their documentation. They were especially interested in codes affected by an RVU change.
An internal review of our coding process in early 2008 indicated the medical coding specialists were reviewing clinical documentation on approximately 60 percent of all patients, and coding was based on that documentation. Our feedback to physicians was both manual and sporadic; and with no transparency, physicians didn’t know what they were doing wrong and they didn’t trust that the changes being made were accurate.

Create a Holding Tank

Our patient business services department recognized providers’ concerns and knew we needed to make feedback available in a way that was both timely and manageable for the coders or the physicians. We also knew from experience it wouldn’t work to send paperwork back and forth or rely on e-mail communication. Instead, we wanted to build the feedback into our electronic patient medical record system, Clinical Workstation® (CWS), which physicians access multiple times a day.
A programmer from Gundersen Lutheran’s information systems worked with our team for approximately 12 weeks to integrate electronic coding feedback into CWS. Now, coding changes are recorded electronically, and physicians and associate staff members receive an alert when they log into CWS. Providers can view all changes made to their evaluation and management codes, along with an educational comment provided by the coder. They can also see all of their notes and an image of the packet they filled out.

A Win-Win Situation

This process has proven useful in more than one way. While we can give providers feedback in a more timely fashion, the providers can also catch errors that our coders have made, allowing the education process to be full circle.
On the feedback site, we provide physicians with an e-mail link and phone number giving them direct access to our coding and documentation education staff. The response from providers has been phenomenal. From the first day the information was available, physicians and associate staff members have called with questions and concerns regarding coding changes. We found there were times when the coder made an error and the physician’s original documentation was correct.
For example, our hand surgeon works in the orthopaedics department, but is considered a different specialty than the orthopaedic surgeons. Patients who were previously seen in our orthopaedic department and referred to our hand surgeon for care were often coded as established patients—a lower RVU. Due to the specialty designation, these patients should have been coded as new patients. The hand surgeon brought this to our attention, and we educated our coding staff.
Conversely, some of our physicians were coding office visits as consultations, which have a much higher RVU, because a patient requested a second opinion. Visits can only be coded as consultations if they were requested by another provider, an opinion was rendered, and our physician responded in writing. In this case, we were able to educate the physicians about the correct way to code and bill for consultative services.
Along with increasing transparency, the project allows us to enhance our education process and increase our internal credibility. The holding tank has led to fewer errors and made us aware of issues that are easy to fix with education.
Ann Bina is the manager of the Coding & Reimbursement section of the Gundersen Lutheran Health System patient business services department based in La Crosse, Wis. She can be reached at

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