Wiki A coder's job duties and workflow

[aimes]

I have been a coder for many years. It has always been set up in all the places I have worked and up until 5 months ago, that charges are reviewed for accurate coding PRIOR to sending the claim out the door. Our coding team, and all the coders I currently know have been trained to take words in the documentation and translate that into CPT, ICD-10, and HCPCS. To us, this is how coding works.
Recently, our coding department has went through a change initiated by Senior Leadership/CFO to change our work flow from reviewing charges prior to release to the following:
1. All providers will choose E&M level that they feel is accurate to the visit.
2. All providers will choose their own ICD 10 codes.
3. Coders are to only review the accurate provider names on the notes,(because the names are never correct); make sure a mod 25 can be applied (if a provider adds one onto the charge, we are NOT to remove it)
4. Coders will correct all the E&M/Dx related code denials after charges have been sent and denials are received OR if it is caught on the back end scrubber.
5. Coders will do a monthly "audit" of 5-10 charts that is done twice a year. All things found will be shared with the provider that was audited.

We have been told that the providers feel it is not a coder's job to "assign" a patient a diagnosis, while we have tried to explain that our role as coder's is to simply match the documentation that is provided to us, we are not changing the actual diagnosis that a provider has given to the patient, only matching what is in the documentation. (We never touch the documentation,we know better, this is simply regarding the ICD10 codes).
We have run into a whole host of issues with this new initiative/job duties.
1. The providers are pulling over icd10 for issues that are not even relevant to the visit i.e. patient was seen for lung cancer and has a icd10 of MI on the superbill and not the lung cancer ICD 10. (We are not allowed to change this, we must send it through) We are encouraged to educate the providers on choosing the correct ICD 10. While this sounds good in theory, in their screen, they cannot "update" or rearrange codes like we can in our superbill screen.
2. ICD 10 codes are coming across that cannot be billed together i.e. excludes codes, unspecified codes, two anemias, ect and thus prompting a huge amount of denials. This is because the providers simply do not know all the many, many rules involved in the coding process.
3. Our denials have went up due to charges not being reviewed by coders prior to release.

We have been told that this is the norm for other practices and that this is how they utilize their coder's. So I am here, trying to find other coders that are doing a reverse process like outlined above. Is there anyone else doing it like this? If so, how is your work flow set up. If not, your input would greatly be appreciated. Job descriptions of what others coders ARE doing on the daily basis would also be very helpful as we are trying to go through this change a little more smoothly and find some suggestions.

Thanks so much!

 

[sls314]

Why in the world would your CFO want to take longer to get paid?

That's what's going to happen by setting a policy that you'll just work denials after the fact rather than send claims out correctly in the first place. You'll also run the risk of not getting paid at all for some claims, because some denials may slip through the cracks and not get worked in time. Why create more work on the back end?

The timing of this also coincides with payers enforcing ICD-10-CM guidelines more and more on their coding. 10 years ago, maybe diagnosis codes could have been haphazardly applied and slipped through for payment. That's less frequently the case now - a number of payers are reviewing claims for unspecified diagnoses and excludes edits. Not to mention that there could be compliance risks involved as well, if you're billing HCCs that aren't valid for the visit.

Additionally, it could confuse patients to receive EOBs for denied claims and give patients the perception that you (the practice) doesn't know what they're doing.

My providers select an E/M level and add diagnoses, because the EMR "forces" them to do so. However, I still review the coding and make corrections as necessary before the claim is released.

 

[carlystur]

I agree with sls314. This is definitely not the norm. Most practices, I believe, would want the claims to go out clean with correct ICD-10 coding and not wait for denials before changing anything. That just gets you delayed payments. That seems very strange to me. I mean, our providers don't want any changes to the codes on the documentation. We use ECW, which adds the diagnosis CODES to the documentation for some weird reason, like this:



But, we can at least change the ICD-10 coding on the claim before it gets submitted.

 

[aimes]

Why in the world would your CFO want to take longer to get paid?

That's what's going to happen by setting a policy that you'll just work denials after the fact rather than send claims out correctly in the first place. You'll also run the risk of not getting paid at all for some claims, because some denials may slip through the cracks and not get worked in time. Why create more work on the back end?

The timing of this also coincides with payers enforcing ICD-10-CM guidelines more and more on their coding. 10 years ago, maybe diagnosis codes could have been haphazardly applied and slipped through for payment. That's less frequently the case now - a number of payers are reviewing claims for unspecified diagnoses and excludes edits. Not to mention that there could be compliance risks involved as well, if you're billing HCCs that aren't valid for the visit.

Additionally, it could confuse patients to receive EOBs for denied claims and give patients the perception that you (the practice) doesn't know what they're doing.

My providers select an E/M level and add diagnoses, because the EMR "forces" them to do so. However, I still review the coding and make corrections as necessary before the claim is released.

Yes, all valid points. These are all things we have brought up in the very many discussions and coding meetings we have had over the course of this transition. Also, the denials we have started to see, are directly related to the oncoming enforcement of coding rules.
Yes, our EMR prompts them to choose both as well, however, our EMR is set up to where the providers cannot do what leadership and the new initiative wants them to take over and do. It's a very coder friendly program.

 

[aimes]

I agree with sls314. This is definitely not the norm. Most practices, I believe, would want the claims to go out clean with correct ICD-10 coding and not wait for denials before changing anything. That just gets you delayed payments. That seems very strange to me. I mean, our providers don't want any changes to the codes on the documentation. We use ECW, which adds the diagnosis CODES to the documentation for some weird reason, like this:

View attachment 6928

But, we can at least change the ICD-10 coding on the claim before it gets submitted.

Yes, I've never seen it done this way before in any other practice. So i'm curious if I can even find any other coders that do it this way.

 

[sls314]

I agree with sls314. This is definitely not the norm. Most practices, I believe, would want the claims to go out clean with correct ICD-10 coding and not wait for denials before changing anything. That just gets you delayed payments. That seems very strange to me. I mean, our providers don't want any changes to the codes on the documentation. We use ECW, which adds the diagnosis CODES to the documentation for some weird reason, like this:

View attachment 6928

But, we can at least change the ICD-10 coding on the claim before it gets submitted.

I probably should have been more specific too just for clarity.

Like you, I do not change anything on the documentation, even though the EMR may pull in a code number. (Which may or may not be accurate)

When needed, I update the ICD-10 coding on the claim itself to accurately reflect the verbiage documented by the physician.

 

[amyjph]

They will change their mind when the revenue drops and takes 3x (or more) as long to come through requiring extensive appeals and corrected claims. Then audits will start coming in too.
I have seen this tried and failed in the past. If it is going to be set up that way there must be an internal scrubber and correction process (that actually works and is updated to rules, etc.) so the claim never makes it out the door in the first place.
If the C-suite and the providers want it this way, there is nothing you can do if you have given feedback up the chain about it.

 

[csperoni]

In my healthcare organization, there are a variety of ways this is done, depending on the provider.
The bulk of the providers do their own coding. A biller reviews for very basic obvious things and sends the claim over to the billing system. The billing system has a claim scrubber that reviews a variety of things (new vs estab, E&M in global surgery period, LCD payable dx, some NCCI), but not all coding issues (NOT excludes1 dx). Most of the profee coders work those scrubber edits as well as coding denials.
There are some providers that the claims go directly from the provider into the billing system without biller review.
There are some providers that are on 100% claim review, which means that every single charge is reviewed by a coder before sending to billing system.
There are some providers that do not code at all, and a coder assigns all CPT, ICD10, HCPCS, modifiers and sends to billing system.
Our number 1 coding denial issue is excludes1 diagnoses, as these are not reviewed by the scrubber. Unbundled is a close second due to not all NCCI edits in the scrubber as well as individual payor policies that do not follow NCCI.
There are SOME providers who understand coding guidelines and are very receptive to feedback and findings. However, this is a small majority. My personal opinion is that a clinician's time and brain power is best spent caring for patients, not counting the number of unique CPT codes on testing ordered. If a certified coder sees an issue, OF COURSE they should be allowed to correct coding.
In your specific case, perhaps the best you can do is hope the appropriate people realize the issues quickly with this new workflow. Otherwise, be prepared to write a lot of appeals and submit corrected claims.
Good luck!

 

[CPalmer]

I used to review 100% of claims. My clinic had a "consultant" come in and sold the uppers on how fast $ could come in by eliminating coders and outsourcing their billing team (of which do not have coders on staff). "It is faster and easier to just bill out without review." The only time charges are reviewed is when the claim is denied. I guess it doesn't matter if the note doesn't match what was done at the visit. I am still on staff, but they removed my coding job duties and let the other coder go. Funny that today I reviewed one patient's charges and 44 visits are WRONG!!! That is only one patient. I try to follow AAPC Ethics - See something, say something. I try to speak up and am told that it isn't my job duty anymore. I am just sitting back waiting for an audit. (I want to add that I have 26 years of coding/billing experience, 6 certifications, 9 certificates, and a college degree).

 

[aimes]

I used to review 100% of claims. My clinic had a "consultant" come in and sold the uppers on how fast $ could come in by eliminating coders and outsourcing their billing team (of which do not have coders on staff). "It is faster and easier to just bill out without review." The only time charges are reviewed is when the claim is denied. I guess it doesn't matter if the note doesn't match what was done at the visit. I am still on staff, but they removed my coding job duties and let the other coder go. Funny that today I reviewed one patient's charges and 44 visits are WRONG!!! That is only one patient. I try to follow AAPC Ethics - See something, say something. I try to speak up and am told that it isn't my job duty anymore. I am just sitting back waiting for an audit. (I want to add that I have 26 years of coding/billing experience, 6 certifications, 9 certificates, and a college degree).

This sounds where they are trying to take our coding department as well. We too are sitting back waiting on the audits that we have tried to forewarn our Sr Leadership of.
Im sure you have seen an increase of denials same as we are from the time of 100% review to current. How long as your clinic been doing it this way? Do you feel they have taken a hard hit of any sort? Or are they happy with the changes? I know we see the impact of not coding but do you feel they are seeing it?