ktreshock
New
Our coders are being asked to recommend screening tests during a pre visit chart prep. As a coder I think that recommending tests/screening is a clinical decision and one that does not fall under our certifications. Any comments?
-
If this is your first visit, be sure to check out the FAQ & read the forum rules. To view all forums, post or create a new thread, you must be an AAPC Member. If you are a member and have already registered for member area and forum access, you can log in by clicking here. If you've forgotten your username or password use our password reminder tool. To start viewing messages, select the forum that you want to visit from the selection below..
Wiki Pre visit coding Coders suggesting screening test
- Thread starter ktreshock
- Start date
I wouldn’t be comfortable doing that.
If a provider determined a screening was necessary and asked me to review whether the patient’s coverage included it, I would certainly advise.
But I wouldn't recommend screenings to providers - that’s a clinical decision, and I’m not a clinician (and I don’t play one on TV!).
Pam Warren
True Blue
Good grief! Do we have to do everything for them? 
I agree with Susan....this is way outside a coder's scope.
I agree with Susan....this is way outside a coder's scope.
Cynthia Hughes
Expert
- Messages
- 464
- Best answers
- 0
This is just my 2 cents as someone who has worked in small practices and had many roles in the past. I agree that coders should not make any recommendations to patients as that would require clinical training.
However, I believe the correctness of the requested "recommendations" might depend on the purpose of the previsit chart prep and to who the recommendation is being made (eg, provision of a list for clinician review). Assuming that coder's recommendation is to a clinician who can then confirm whether the preventive service should actually be recommended to each specific patient (eg, determine that a patient on cholesterol medication is not eligible for lipid screening), this would not be clinical work. If verifying insurance benefits is part of the chart prep, it should be easy for a practice administrator or physician to provide coders with recommended A or B preventive services by general patient characteristics (eg, AAP periodicity table for childhood preventive services, https://www.womenspreventivehealth.org/wellwomanchart/) that could be used to determine what services may be recommended and whether the patient's insurance shows eligibility for any or all of the recommended preventive services. (If you work in a practice that sees Medicare patients, a plan for future preventive services is developed as part of the AWV and would be useful for this purpose.)
I bet there are a lot of coders who would never expect to do chart prep and others who fill many different roles in smaller practice settings. While I would agree that a coder should never perform any action that requires nursing or other clinician training and licensure, working to help patients and providers make the most of each visit doesn't necessarily require clinical skills. One of the most important tips for practices today is to make the best use of each staff member's skills. Coders have the skills to use provider portals and patient billing history determine if the codes that represent recommended preventive services have been reported within a specific time period and whether the patient is eligible to receive the services if a clinician then orders or provides the service.
I would encourage asking questions before reacting as what could be an inappropriate request might actually be an opportunity to help the practice improve the quality of care and potentially increase revenue.
Cindy
However, I believe the correctness of the requested "recommendations" might depend on the purpose of the previsit chart prep and to who the recommendation is being made (eg, provision of a list for clinician review). Assuming that coder's recommendation is to a clinician who can then confirm whether the preventive service should actually be recommended to each specific patient (eg, determine that a patient on cholesterol medication is not eligible for lipid screening), this would not be clinical work. If verifying insurance benefits is part of the chart prep, it should be easy for a practice administrator or physician to provide coders with recommended A or B preventive services by general patient characteristics (eg, AAP periodicity table for childhood preventive services, https://www.womenspreventivehealth.org/wellwomanchart/) that could be used to determine what services may be recommended and whether the patient's insurance shows eligibility for any or all of the recommended preventive services. (If you work in a practice that sees Medicare patients, a plan for future preventive services is developed as part of the AWV and would be useful for this purpose.)
I bet there are a lot of coders who would never expect to do chart prep and others who fill many different roles in smaller practice settings. While I would agree that a coder should never perform any action that requires nursing or other clinician training and licensure, working to help patients and providers make the most of each visit doesn't necessarily require clinical skills. One of the most important tips for practices today is to make the best use of each staff member's skills. Coders have the skills to use provider portals and patient billing history determine if the codes that represent recommended preventive services have been reported within a specific time period and whether the patient is eligible to receive the services if a clinician then orders or provides the service.
I would encourage asking questions before reacting as what could be an inappropriate request might actually be an opportunity to help the practice improve the quality of care and potentially increase revenue.
Cindy
Pam Warren
True Blue
Although I can see how making recommendations to meet medical necessity might be ok, such as suggesting to a provider that they perform a medically necessary exam for a patient with a skin condition, I would not feel comfortable data mining a chart in advance of a visit and advising a physician to order/perform certain services based on clinical criteria. Besides not feeling that I have any level of clinical understanding (such that I would recommend lipid screening for a patient with a BMI over 40, which is clearly not my call....) that same lipid screening is a billable service, and as a coder, I don't want to make recommendations to inflate charges for the patient. That is up to the provider. At the very least, I would be comfortable saying to the provider, "this patient has a BMI over 40. Please consider addressing this at the next AWV". Let them make the decision as to what diagnostic/screening studies to order.
Cynthia Hughes
Expert
- Messages
- 464
- Best answers
- 0
I absolutely agree but the question noted the coder was "asked to recommend screening tests" which are not medically necessary by nature. Again, I encourage that this request be further discussed with the appropriate management to determine if the request is actually that the coder identify those preventive screening tests for which the patient may be eligible for health benefits (without patient costs) on the date of service to help physicians close gaps in care. This is no different than identifying whether the patient is still eligible for their annual wellness visit prior to the visit (a very important nonclinical task that prevents physicians from providing the service only to learn that another provider has already provided and billed the once per year service). Practices are not trying to inflate revenue by taking every opportunity to provide recommended preventive services but rather increasing the quality of care and, if screening results lead to early diagnosis and management, potentially reducing the cost of care which is really important to physicians under value-based purchasing.
My comment, "a clinician who can then confirm whether the preventive service should actually be recommended to each specific patient (eg, determine that a patient on cholesterol medication is not eligible for lipid screening)," was intended to emphasize that even when the patient appears to be in the population that is eligible for a recommended preventive service, a clinician still needs to review the patient's history to confirm the patient is not excluded from the recommendation.
If I still seem to be recommending that coders should make clinical recommendations, then please ignore my comments as that is not all my intent.
Cindy
miriambroyles
Contributor
I guess it depends which screenings your coders are being asked to recommend and for what purpose. Some screenings are needed to meet HEDIS measures such as fundus exams for diabetics. If on a pre-visit review no fundus exam is found in the chart that meets the HEDIS diabetic eye exam criteria, it seems it would be appropriate for a coder to call that to the attention of the provider in an effort to meet the requirement. Just a thought.