Primary Care Coding Alert

Interpretation: Many coding rules and guidelines are open to interpretation. Clinical documentation disputes are incredibly common as coders, physicians, and payers can all have legitimate arguments in favor of their points of view.

Consider the “Why” to Help Motivate Doctors

Like anyone else, if doctors don’t understand how good coding and thorough documentation directly affects them or their patients’ care, you won’t have their attention. “Coding touches every patient encounter. Treat it that way,” said Church.

Whether it’s compliance, contractual obligation, revenue optimization, resources to pay staff better or give more bonuses, morale, or more resources to expand care, there are a plethora of reasons to care about better documentation and accurate coding. Sometimes, the biggest motivation is simply better pay and more reimbursement. “Remember, pay shouldn’t be what drives the work, but lack of pay can prevent great work,” Church said.

Consider Teaching These Concepts First…

We think of doctors as really smart, and with good reason. They are. But coding is not easy, and there is plenty of nuance. Doctors need to start off with easier coding concepts that are relevant to their everyday workload. Give them the opportunities to have success that they can then build on.

Evaluation and management (E/M): A good place to start, especially in primary care, is with the office/outpatient codes. Typically, these are the most common services provided by primary care physicians. Start with a discussion of what constitutes a medically appropriate history/exam, then break down the medical decision making (MDM) chart into small pieces, one column at a time. E/M isn’t straight-forward, but it does affect every encounter. So, begin by giving your providers bite sized concepts they can apply right away and use techniques such as mnemonics, white boards, notes, and the like.

Diagnosis codes: The ways doctors learn about diagnoses in medical school don’t always translate to the ICD-10. A lot of what’s in the code book simply doesn’t match up with the doctor’s language. “Start with the most common codes and conditions,” said Church.

Annual Wellness Exams: With Medicare’s wellness exams, there is a set of check boxes, and it’s easy to see on paper what is required for the exam. “Docs tend to do well with specific, clear rules,” said Church. “Cite the source there. Remind them these are guidelines that you didn’t make it up. Docs are used to things being citable/scientific/precise,” he added. Note that while these aren’t glamourous or interesting, Medicare pushes them for a reason. These kinds of exams can make a huge difference for preventive medicine. “It’s a crucial part of the ‘why,” said Church.

Common procedures: Just as you would start diagnosis coding education with commonly used codes, begin procedure code education with your provider’s bread-and-butter procedures and build their knowledge base from there. In primary care, these tend to be integumentary procedures (e.g., skin biopsies and lesion excisions), joint injections, other therapeutic injections, etc.

… And Teaching These Concepts Later

Modifiers: Modifiers can get tricky, so it’s best not to introduce them right out of the gate. However, it’s good to work on these as you go along. It opens your providers’ eyes to show them how to bill atypical situations or more than one service at once.

Risk adjustment: “Risk adjustment is like an advanced primer on diagnosis coding,” explained Church, so start on this around the end of the first year. Think of it like this, he continued. “You don’t teach to the adjustment factor. You need to teach to the accurate diagnosis coding. The rest works itself out.”

New relevant code releases: As new codes come out, be sure to keep everyone up to date on the changes that will have the greatest impact on them, such as the recent split/shared visit update or changes to how time is calculated for E/M visits.

Take In These Onboarding Recommendations

When making coding education part of your onboarding process, ease your provider into it in a logical way. Mix it up, incorporate active recall, easy-incentive quizzes, and show real examples. Use the following timeline as a template:

• First meeting: Revenue cycle process
• Second meeting: Documentation requirements in the note
• Third meeting: How to level service and time-based billing
• Fourth meeting: Review notes and show how to level services
• Fifth meeting: Review of redacted notes that residents have billed and any areas of opportunity.

Remember, you are building relationships and trust. Emphasize how difficult and confusing coding is. “Think of a grocery store,” explained Church. “There is an agreement between the grocer and patron. It’s the same with coding. You can’t leave items in the cart and walk out. You also can’t scan things twice,” he continued.