Anesthesia Coding Alert

Fall can mean an influx of new providers, thanks to recent graduates joining practices or established providers making changes based on personal or family needs. However often your practice welcomes new providers, setting a strong foundation is paramount for all parties involved.

Follow these three tips to communicate the nuts and bolts of some coding realities to clinicians.

Tip 1: Map Out a Plan

Providers need to know a lot of information about your practice and how processes work. Taking time to organize their onboarding helps everything go smoother, from knowing every piece of information a new provider needs to ensuring you cover everything.

Using a template for all onboarding is one way to get organized, says Victoria Moll, CPC, COC, CPMA, CRC, CPRC, CEO of Contempo Coding LLC in Fleetwood, Pennsylvania.

Here’s why: A template will help you make sure that you don’t forget any crucial information.

Clinicians are trained to provide patient care, so you don’t need to go over all those details. However, covering some aspects of documentation and other sort of paperwork is important. If your office has a template for inputting patient information or other form of electronic health records (EHR), make sure your clinician knows the ins and outs of how to best report that documentation. Highlight how problematic it is to copy and paste information between patients or between patient encounters.

Concentrate on documentation requirements, common errors, expectations from other staff — especially what information other team members need to do their own jobs — and who the provider should go to with any questions.

“Don’t make your doctor be a coder,” Moll says. At the same time, there’s nothing wrong with being clear about what the provider can do to help make coding easier and reimbursement more accurate.

Tip 2: Train from the Provider’s Perspective

“What is important to you when auditing a note is not what’s important to a provider,” says Shannon DeConda, CPC, CPMA, CEMA, CMSCS, president of NAMAS and partner at DoctorsManagement with offices in Knoxville, Tennessee, and Gainesville, Florida.

A provider’s job is patient care, so everything centers on that. Keeping this in mind, focus your training on what providers need to know about documentation necessities such as accounting for time or how your practice interprets the rules of medical direction. Then communicate that information by framing it around patient care.

“Documentation validates the care; we must always remember that this is their perception,” DeConda says.

Tip 3: Make Audits Work for Everyone

Audits conducted by your own practice can be a useful tool for everyone, from figuring out what needs work to what requires better communication.

As you onboard new providers, frame audits as a regular means of checking in. Decide — and tell — them how many audits you will do, within which timeframe.

In the meantime, track your trends. Analyzing that data can help you decide the timeframe in which you review, how many cases you’ll audit, whether there should be a pass/fail threshold, and the necessary follow-up protocol, Moll says.

When you do follow-up, don’t approach the provider with a readthrough of every single case. Do the work ahead of time to figure out what can be improved and how, so you can approach the provider with opportunities to improve instead of errors to be reconciled, Moll recommends. Make it a conversation.

Bottom line: Training providers who are new to your practice doesn’t have to be a headache for everyone involved. Get organized, determine what constitutes a “best practice,” and what will work for the minimum quality you’ll accept, Moll says. Set — and communicate — expectations, as well timelines for following up.