Ob-Gyn Coding Alert

Other than noting [claim] rejection reasons and rates many practices dont have a good estimate of how theyre doing, observes Jan Rasmussen, CPC, coding consultant and instructor for Med Learn, a medical practice management training and consulting firm in Minneapolis/St. Paul, MN. Reviewing these six key indicators can help determine how effective your coding process is.

1) Produce a Statistical Overview of Your Codes. Statistics give you the big picture, Rasmussen states. While some practices do not take the time to run these overall summary reports, Sandra Darrow, office manager for Womens Health Care Associates, of Annapolis, MD, says her practice runs them monthly. This gives an overview of what services they are providing and the mix in the types and levels of codes being used. One can see whether there are patterns of up or down coding taking place. Both CPT and diagnosis codes should be evaluated.

CPT: Within CPT codes, review the mix of E&M codes. Are all levels of services represented? Is a certain level of E&M office visit being used more than others? Some red flags may be a tendency toward the higher end or lower end of office visits or the consistent use of only one level. Other danger signs are an imbalance of consultation codes verses new patient codes, an obvious lack of preventive medicine services or the absence of Medicares new breast and pelvic exam code G0101. Many physicians only bill preventive medicine services for patients under age 65, whereas they actually are billable for older women as well.

ICD-9: Diagnosis codes should be evaluated by examining the top 20-25 codes used for the year. Evaluate their specificity. A high use of .8 and .9 codes indicates the diagnoses could be more specific. Also, look for missing 5th digits, and whether or not the codes are being carried out to the appropriate digit.

2) Review Explanations of Benefits (EOB) and Rejections. The next important indicator is whether there is a process for reviewing EOBs, says Rasmussen, who obviously feels they should be. Next to your statistics, EOBs can give you the most information about the coding process, she says. Your rate of rejections will depend a lot on your payor mix. Rejection rate is really not the defining factor, although it can help identify trends or a specific problem in the manner in which certain procedures are coded. But the review process should extend to encompass of the reasons for the rejections. This analysis should look closely for reasons such as unbundling, whether or not the diagnosis codes support the claim, modifier usage and if an explanation is being requested. It is important to note that repeated unbundling of services can draw attention from the carriers and trigger an audit.

Further, examining your EOBs is also a good check on the insurance companies, says Sherry Braithwaite, insurance clerk for Harrisonburg Physicians for Women in Harrisonburg, VA. Sometimes we find that the insurance company has made an error. If the coder is lacking in training or experience it will show up here. The use of incorrect codes, a lack of familiarity with correct edits, modifier usage and familiarity with carrier requirements may all come to light when evaluating EOBs. But its also important to note that low rejections are not an indication that coding is being done correctly. It could be you have a very uneducated insurance company paying incorrect claims, says Rasmussen, It is important to look at the EOBs of all carriers. You also want to review payments if you are in a contract with a particular carrier. You should be sure you are getting paid what your contract stated. For carriers without a contract, it is important to look at full payments. Consistently being allowed what you charge may indicate your charges are too low.

3) Look at Charge Tickets (or Encounter Forms). You can tell a lot about a practices coding by looking at what appears on the charge tickets used by the physician, says Rasmussen. Above all, charge tickets should be up to date and reflect current and appropriate codes. Does the charge ticket list all levels of E&M codes, including preventive codes? Are diagnosis codes appropriate for the practices activity and carried out to an appropriate specificity? In addition, do the codes on the charge tickets themselves reflect what the practice is actually doing and assist the physician in correct coding? Beyond just evaluating the encounter form, pull a few charts and evaluate whether or not hand written or marked diagnoses on the form are supported by the documentation on the chart. This is the number one problem in ICD-9 coding, Rasmussen warns. The physician may mark one diagnosis on the charge ticket, such as cervical dysplasia, but state abnormal Pap smear, probable cervical dysplasia, in the documentation.

4) Capture all Activity. There should be a mechanism for coding and tracking all patient visits and practice activity, even if it is not revenue producing or part of a global billing. While not solely a coding issue, a significant area of lost revenues is in services that never make it to the coding process. Rasmussen, who assists practices in evaluating their coding process, says that in a brief look at one ob/gyn practice she found $25,000 in uncaptured revenue.

There needs to be a process in place for comparing the appointments with what actually gets coded and billed, she says. Does your practice have more appointments than charges? Is there a mechanism for ensuring that each appointment is actually coded (whether billed or not)? During the statistical review, specifically compare the mixture of office visits and prenatal care visits with global coding. If you are only billing global codes for ob patients you may be missing additional revenue. Ob/gyn practices can lose revenue by not capturing extra visits and by mistakenly including complications or unrelated services during a pregnancy in the global code. In the same way, complications during labor, delivery and postpartum care are also lost in the global.

Still another area that needs to be monitored is whether the ob patient has had a change in status. For instance, tracking a patient who does not complete her term -- whether she moves, changes physicians, miscarries, or changes insurance carrier. Because so much ob activity is captured in the global billing, prenatal services only may be lost within a busy practice. There must be some method of communicating interrupted global services so the revenue for services up to the point of interruption is not lost.

Along with tracking patients, it is also important to have a parallel tracking system for supplies and injections. Pessaries are expensive items and easy to miss on the charge ticket. Injections like Depoprovera can be missed because some insurance plans have the patients pick up their own medication for injection at the pharmacy, while others require the drug to be supplied by the practice. A clear system for tracking such items needs to be in place.

5) Responsibility, Education and Training. A coding process that is serving its practice well will share responsibility for coding between the physicians and the billing department. Some of the best coding processes are those in which coding does not rest solely on the shoulders of coding personnel. We provide constant feedback about coding to our physicians, says Braithwaite. Either in monthly meetings or by going individually to each physician.

We recommend that physicians have some responsibility for selecting codes and that the coding is verified by trained coders, especially surgical coding, Rasmussen says. Ongoing periodic educational E&M audits with direct physician feedback will help the physicians understand the relationship of documentation and coding. Physicians need some ownership and understanding of coding to understand the importance of documentation. After all, it is the physicians license at stake in an audit situation.

6) Internal and External Audits. The final key indicator of a quality coding process is whether your practice conducts audits. Internal and external audits should be performed as often as necessary based on the needs of the practice. If during an initial random audit specific problem areas are identified or the paperwork of a particular physician has a high error rate, more frequent attention to such zones is warranted, Rasmussen says. You may want to develop an internal audit program based on error rates calculated by an individual physician. As the doctor decreases his or her error rate, that particular physician or area of concern (i.e. consults) is reviewed less frequently. It is also helpful to have annual or biannual reviews by an outside company to provide insight and support to the coding staff. Any good coder can become bogged down by the frequent changes in coding regulations and carrier interpretations. An outside audit will help identify those areas.