ED Coding and Reimbursement Alert

By Caral Edelberg, CPC, CCS-P, president of
Medical Management Solutions Inc. in Jacksonville, Fla.

With compliance concerns at an all-time high, emergency physicians are attempting to control potential errors from coding staff through use of a superbill or coding charge sheet. Although this concept is not new to emergency medicine, its resurgence bears discussion of the pros and cons of using such a short-cut method to determine codes and charges.

How Physicians Can Address the Issue

Having physicians involved in the code assignment through ongoing coding training can be beneficial. Many groups believe that by assigning the actual billing code, physicians are reminded about how charts should be documented and can easily clarify any code options by assigning the code that most closely reflects the procedure or service that was performed. However, coding must be performed on the service that is documented, not the service they think the physician feels he performed.

Unless physicians understand that the coding system works that way, assigning their own codes may place them at a higher level of risk of charges of fraud or abuse.

Physicians who choose to do their own coding through use of a superbill form should be aware of these eight points:

1. All coding should be reviewed by a trained coder to
ensure the documentation supports the code assigned.

2. Coders should assign the modifiers prior to billing.

3. Coders should assign the ICD-9 diagnosis codes to
assure that the CPT and ICD-9 codes match and demonstrate medical necessity.

4. Coders should provide routine feedback to the
physicians when codes are assigned incorrectly.
5. Physicians should be clear that their code assignment, if incorrect, will be changed by the coder.
6. Physicians should be expected to maintain a
minimum number of hours of orientation to correct coding.

7. Physicians should be advised of how codes are paid
and/or denied by major payers. This can be accomplished by a routine review of payment remittances.

8. External quarterly audits should be required as part
of the compliance program to identify coding errors
made by either physicians or coders.

Physicians should be aware that, from a compliance perspective, it is advantageous to have codes and charges assigned by someone with no incentive to upcode. If physicians are indeed paid by what they code and audit problems occur, it will be more difficult to demonstrate that a clear division between coding and revenue exists. In other words, when physicians are removed from the coding process, there can be no suggestion of involvement in upcoding for monetary gain.

This does not mean that when a trained coder performs coding, the physician should ignore his or her responsibilities. On the contrary, no matter who performs the coding, the physician is ultimately responsible. That is the law. So physicians should be prepared to be involved in monitoring the process regardless of who actually does it. The rule of coding should be: Whoever knows the rules assigns the codes!

Eight Tips for Correctly Using a Superbill Format

1. Forms should list only current and correct codes. This means that forms must be updated at least once per year.

2. Forms must not abbreviate code descriptions. Abbreviations of descriptors can result in misleading information and incorrect code assignment.

3. Never select ICD-9 codes from a superbill form in the emergency department. There just isnt enough room to list the ones you need!

4. Be sure to leave plenty of blank spaces for physicians to enter additional procedures that are not listed on the form.

5. List procedures by family. That is, keep like procedures together for ease in locating. Ask the physicians to assist in the layout so they are comfortable with the format.

6. Be sure the print isnt too small.

7. Be prepared for a two-sided form. Emergency medicine has grown to encompass services never anticipated for performance in an emergency environment when the specialty was first recognized.

8. Be sure to check with the physicians about how the
form is working. Be prepared to revise the form when it becomes problematic or isnt used as intended.

background on Superbills The initial intent of a superbill was to provide the patient with a statement of codes and charges that could then be given to the third-party payer as verification of the services that were provided. This helped to alleviate much of the follow-up billing that would be required when the physician engages in the tug-of-war with the insurance company and is left with the responsibility of billing the patient. Initially, the form listed the most common services provided by the physician with their associated CPT codes, as well as a brief listing of diagnoses with their associated ICD-9-CM codes. Usually, there also were several blank spaces for the physician to write services that did not appear on the form. In order for the superbill to do double duty as a claim form, each one required that the tax-ID number of the physician or group providing the service be on the form as well as the provider number of the performing physician. As coding became more complex, it became difficult for any code sheet to provide a comprehensive and accurate list of the CPT codes and ICD-9 codes that might be needed in the ED. In addition, as medical necessity became more significant for third-party payers, reporting the right combination of CPT and ICD-9 codes grew to be a crucial payment issue. Physicians found that coding was becoming a specialized area that required knowledge of code content, considerations for when evaluation and management and procedures were combined, and a clear understanding of how modifiers were required to correctly limit a code to assure accurate description of the services. ICD-9 codes, once elective for use on the claim form, became mandatory and more complex each year. Without some training and experience in selecting the appropriate specificity level for the diagnosis code, a physician might code incorrectly and generate a payment reduction or denial. Why Superbills Are Used As the practice of emergency medicine has evolved, many groups have shifted from a flat hourly rate for their physicians, to a fee-for-service arrangement where the doctor is paid just what is collected for the patients he or she sees (after an adjustment for billing expense). This has encouraged physicians to take a greater interest in documenting their services correctly and in how those services are translated into the coding language of CPT. In most practices, the doctors code selection is overread by an experienced coder who determines the accuracy of the codes and, in some instances, must change the code to a more accurate one to reflect the service as it is documented. This practice can, and often does, create problems between physicians and coders. Physicians may take their own code assignments to the bank, anticipating their monthly charges based on their own code assignmentthen find their charges have been revised by the coder overreading their charts. The issue is further complicated when the physicians have limited knowledge of coding rules and dont understand why the coder is questioning their coding decisions. In addition to the revenue considerations, some physicians feel more comfortable assigning their own codes as protection from potential risk of errors that someone else might make. With all the discussion about compliance, physicians have become more concerned than ever about upcoding of their charts.