Healthy Documentation Starts with You

Form relationships with your physicians that promote communication.

By Terri Brame, MBA, CHC, CPC, CPC-H, CPC-I, CGSC

If not handled correctly, communication between coder and physician can be frustrating for both parties. In 15 years working with physicians, I’ve had as many different physician interactions as I’ve had physician meetings. I’ve also learned how to keep the lines of communication open so that everyone in the practice benefits. By keeping a few things in mind, you can make the next meeting with your physicians successful and enjoyable for everyone.

Do Your Part

Unless you are a clinician as well as a coder, avoid making clinical statements when discussing coding and documentation. For example, say to physicians, “I am the CPC® and you are the MD,” to be clear that you are not making diagnostic decisions or judgments regarding the care provided. When talking with physicians about coding and documentation, use language that applies to coding and documentation, and not to the clinical work it represents.

The physician is the best arbiter of what work is medically necessary. Avoid statements such as, “You can’t spend that much time talking to a patient about X diagnosis,” or “That exam element is never done for X chief complaint.” It may be that the service was unusual. Your job is to coach the physician in properly documenting his or her services so that you may accurately code them. It is not your job to judge whether the work the physician performed was necessary.

Be a Partner, Not a Policeman

When you first meet with a physician, don’t dive right in and start making suggestions for how to change his or her documentation practices. Instead, start the conversation by asking the physician to tell you anything he or she thinks you should know about the practice. A couple of reasons to do this are:

Every physician’s practice is a little different. It’s good to hear from the physician about the unusual details of the practice before providing coding and documentation recommendations. That way, you won’t waste the physician’s time talking about things that don’t apply specifically to his or her practice. For example, if you have only 30 minutes with a physician, you’re doing the physician and yourself a disservice by spending 10 minutes talking about hospital services if your physician doesn’t see patients in the hospital.

It’s an opportunity to learn the business of healthcare. You can better apply coding and documentation rules if you understand how the practice operates. This understanding also can create a feeling of partnership between the physician and you.

During the meeting, try to keep an open dialogue: Do not speak at physicians, talk with them. As you’re providing guidance, check in with them: Does this make sense for the practice? Does it fit with your documentation habits? If not, work with your physician to determine how to make his or her practice and the rules for coding and documentation coincide. Be ready to think creatively about how best to achieve this.

Make it clear that you want your physician to collect all of the reimbursement he or she is appropriately due, and you want to minimize any risk to the practice. The physician’s success is your success. Your interest is making the rules work for the practice, rather than getting the practice to conform to the rules.

Which Came First: the Service or the Code?

Coders and physicians sometimes move away from the concept that evaluation and management (E/M) codes were created to represent services, and instead try to make a service match the desired code. The physician should provide medically necessary services, fully document those services, and report the CPT® code that accurately represents his or her effort—in that order. Especially when considering E/M services, discuss with your physician what must be documented to report a certain service.

For example, physicians and coders sometimes fall into the trap of thinking that specialists should always bill high-level services. With that assumption, the physician will work backwards to include what the documentation should state to support the desired service level, and the coder will follow suit. To remedy this, meet with the physician to learn of the actual services he or she provides for different common chief complaints. Then, discuss with the physician ways he or she can document those services so that you can select an accurate E/M code level.

This is an opportunity to be open to possibilities. Talk to your physician about whether he or she is actually providing a time-based service. That is often the case when the physician can’t get the note to meet the level he or she thinks is correct for the service.

Why Don’t I Get Paid for That?

You may have heard that postoperative E/M services aren’t billable, or that they are free services. What this conversation is often really about is the amount of reimbursement for the service, which is not the same as discussing a global package.

When a surgical package is developed, it includes the work and reimbursement for many services beyond the actual operation. As well, most payers consider many non-face-to-face services, such as telephone calls between clinic visits, as bundled with the most recent clinic visit.

When discussing this sort of thing with your physician, explain that the service was reimbursed as part of another code; it has already been paid. Reporting such services separately would mean reporting the same service twice, which would be wrong. Your physician will appreciate that you are looking out for his or her best interests.

Clarify Terms to Avoid Miscommunication

Physicians and coders may use the same terms to describe different things. For example, physicians usually don’t make a distinction between the terms “consult” and “referral,” while coders understand them to mean two different things. As well, some specialty physicians consider all new patient visits eligible for consultation service codes because they do not see patients without a referral. When discussing these terms from a coding perspective, clarify that you are discussing the requirements necessary for the CPT® Consultation Services codes.

Another common term that can mean one thing to a coder and another thing to a physician is “critical care.” Physicians that care for patients on intensive care units (ICU) may consider all services they provide to be critical care services. They might also think the Critical Care Services CPT® codes are actually ICU services codes, and that those codes are used for all services provided on the unit. Take time to talk about these common terms and how they apply to coding guidelines versus the physician’s practice to ensure everyone is speaking the same language.

Be Passionate About What You Do

I am mission-driven in my work with physicians. The smoother I can make the business of medicine run, the more time and effort the physician will have to treat patients, which ultimately means I can indirectly affect patient care. Figure out what motivates you as a coding professional and let your physicians know. This open communication is what builds healthy relationships in a practice, which is to everyone’s benefit.

Terri Brame, MBA, CHC, CPC, CPC-H, CPC-I, CGSC, is the compliance education officer for the University of Arkansas for Medical Sciences. She is also the author of “E&M Coding Clear & Simple, Evaluation & Management Coding Worktext,” published in Taber’s by F.A. Davis. Brame is a member of the Little Rock Central Arkansas local chapter and past local chapter president.


Renee Dustman

Renee Dustman

Renee Dustman is executive editor at AAPC. She has a Bachelor of Science degree in Journalism and a long history of writing just about anything for just about every kind of publication there is or ever has been. She’s also worked in production management for print media, and continues to dabble in graphic design.
Renee Dustman

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Renee Dustman is executive editor at AAPC. She has a Bachelor of Science degree in Journalism and a long history of writing just about anything for just about every kind of publication there is or ever has been. She’s also worked in production management for print media, and continues to dabble in graphic design.

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