Ob-Gyn Coding Alert

Rapidly getting bills out to payers is becoming more critical for many ob/gyn practices. Cash flow issues are getting bigger every day, says Cynthia Thompson, senior consultant and coding expert with Gates, Moore & Co., a medical practice management consultant firm based in Atlanta. With declining reimbursement, payers scrutinizing claims, and competitive contracting, practices are being forced to operate closer to their margins. Therefore, a practices ability to ensure a positive cash flow is increasingly tied to its ability get services quickly coded and off to payers. This article will help coders, billing supervisors, and practice mangers assess their billing and coding processes, identify delays, and increase their efficiency.

Find the Problem

1. Understand your process. When assessing how fast or slow a service is turned into a bill, ob/gyn practices need to first consider that coding and billing is a key business process that includes various players and systems within a practice, cautions Thompson. No matter how large or small a practice, each has its own unique process for turning services into bills. She also cautions that there is no clear benchmark for how fast a service should be coded and billed. We like to say as soon as possible, she says. Hopefully within 24 hours of the completion of the service, but that depends on so many variables that are clinic specific.

Before any efforts are made to speed up or change your billing and coding procedures, they must be understood. A useful method is to make a flow chart of exactly what takes place in the billing process. Start the chart with what occurs in the front office when insurance information is verified. Then, move through the provision of the service. How, exactly, is the information documented, posted and conveyed to the coder, and finally, sent off to the payer? Actually writing and drawing out your process will help illuminate the interconnectedness of each part.

Note: Ob/gyn practices may need to make two charts: one to track office activity and another to track hospital activity.

Subsriber benefit: See bound-in insert (pages 1-3) for examples of flow charts that can be instituted in your practice.

2. Identify process delays. With the flow chart in hand, you can now begin to pinpoint where bottle necks and delays are occurring in the process. Remember, you should try toidentify problems, not peopleand solicit the input of everyone involved. Some common delays stem from:

Incomplete insurance verification in the front office

Hospital activity that is not supplied by the physician to the coder in a timely manner

An encounter form that is not clear or easy to use for both provider and coder

Information from provider that is incomplete or illegible

Volume of posting too great for the number of coding staff

Dictation/transcription delays

Incomplete reporting of services or procedures

Returned bills due to incorrect coding

Lack of familiarity with payers

Jan Rasmussen, CPC, coding consultant and instructor for Med Learn, a medical practice management training and consulting firm in Minneapolis/St. Paul, says that one of the most common problems is linking provider documentation with diagnosis codes, which may have roots in both the lack of provider education and inadequate encounter forms.

Solving Problems Once You Find Them

1) Enlist key players in creating solutions. With a grasp of where in the process your billing and coding delays reside, you need to enlist the support of everyone involved. Thompson points out that two of the key players in this process are the provider and the coder, and both must recognize the need for finding solutions to delays. If a thorough assessment has been conducted, both will be able to see the connection between the delays, their roles, and the effects delays have on practice cash flow. Solutions will be as individual as the practice, the process, and the people involved. The secret is in a cooperative environment where problems are not just seen as being the doctors problem or the coders problem but where everyone works toward a solution.

2) Continual education of the provider. Spend time educating your ob/gyns as to appropriate coding, and you will improve your turn around time, says Rasmussen. She suggests that coders have regular meetings with the physicians to train them on the specifics of coding. For example, gynecologists need to know they must write more than PID (pelvic inflammatory disease) on the chart because there is no diagnosis code for PID without more specifics. Barring the ability to have regular meetings, she suggests that coders educate their providers by continually asking the physician for information and slowly instructing them about what needs to be in the chart.

3) Give providers useful tools. Coming in a strong second is what Melanie Witt, RN, CPC, MA, program manager for the department of coding and nomenclature at the American College of Obstetricians and Gynecologist (ACOG), calls tools to transfer the information. These include staff-designed encounter forms that enable the provider to communicate in terms that the coders and billers will understand clearly. Also included are specialty-specific coding tools for providers that enable them to refer to codes when dictating or charting, as well as tools that rapidly and accurately record hospital activity so it can be reported back to the office.

4) Code it right the first time. All of our experts agree that one of the biggest delays comes when the bill is returned because of incorrect coding. Were the diagnosis codes in the right order or carried out to the most specific digit? Were the V codes, ICD-9 codes for circumstances other than disease or injury, properly used? Does the coder have a good knowledge of the payer requirements? Getting it right the first time relates to the training, experience and skill of the coder. Next to the physician, Witt says, the coder is one of the most important people in the office and must be highly qualified. There is considerable disagreement on how much training and experience a coder must have, but our experts agree that investing resources in coding personnel on an ongoing basis is extremely valuable to the practice. Several experts mention that coding is not a job that can be simply performed by someone promoted from the front office without adequate training and experience.

5) Hire enough coding staff. An important question is whether or not you have enough staff to handle the volume of coding. According to Thompson, many practices coders are over burdened with a huge volume of postings that may cause delays or errors. According to the 1997 MGMA Cost Survey, ob/gyn practices typically have 0.47 billing staff (including coders) for every full-time provider. Rasmussen cautions that ones staffing needs cannot be based solely on these figures, but need to take into account the way a clinics billing process is functioning. She points out that coding and billing staff needs depend both on the coding awareness level of the providers as well as the competency of the coder. She says, If your ob/gyns are providing you with information you need and you arent spending a lot time looking for answers, a single coder can meet the needs of multiple providers. Still, others suggest that in the billing office, its better to be overstaffed than understaffed, pointing to the direct correlation between billing staff, cash flow and revenue.

6) Make coding a priority. Coding expert and instructor Thomas Kent, CMM, says a significant portion of coding delay in smaller practices occurs because coding is not always a top priority. He mentions the frequently encountered situation in which a front-office staffing shortage pulls people from the back office, resulting in coding delays. Cynthia Thompson even goes further and points out that, in many practices, the coder is doing multiple jobs and may even be the practice manager. The further the coding is from the actual service provided, she notes. the more likely there will be errors.