Ophthalmology and Optometry Coding Alert

Three different roles, the same shared goals.

In her presentation “Documenting and Coding From the Clinician’s Perspective,” at HEALTHCON 2024, Lynn Rapsilber, DNP, APRN, ANP-BC, FAANP, NP Business Consultants LLC, stressed the importance of recognizing shared goals between clinician, coder, and biller, even though each individual’s task is different and each individual’s understanding of the others’ tasks may be unclear.

However, despite the obstacles in the relationship between these three roles, all share the same goals. All should try to deliver effective healthcare, improve financial performance, and create better patient outcomes. This means listening to each other, communicating and improving education opportunities, and using technology to improve workflow and enhance data utilization.

Here are a number of Rapsilber’s observations about the roles of clinicians, coders, and billers, and strategies for overcoming the problems that can occur in the relationship between these key team members.

Begin by Understanding the Barriers

Rapsilber began by identifying the main obstacles in the relationship between clinician, biller, and coder. “Providers lack billing and coding education in their training, while billers and coders cannot effect change, and all of these things affect the bottom line,” Rapsilber noted.

Or, to put it another way, clinicians are there to diagnose, treat, and manage patients. The coders’ job is to understand medical terminology and coding systems, and translate clinical documentation into standardized codes, while the biller’s job is to complete the revenue cycle, as they are responsible for submitting claims and handle denials.

Then Understand the Role of Documentation

Rapsilber reminded her audience that, no matter what their responsibility, all need to rely on accurate documentation. “Details matter, and we all need to do our work accurately and in a timely manner,” Rapsilber noted.

This means clinical documentation improvement (CDI) should be the most important area of collaboration for all involved in the revenue cycle. All must ensure that documentation accurately reflects the severity of the patient’s condition(s) and clearly states the details of the care management plan.

So, in the CDI process, there are opportunities for coders to educate clinicians about documentation pitfalls, while clinicians can share insights about complex conditions and management with coders, Rapsilber noted.

Ultimately, however, the burden of responsibility for accurate coding lies with the providers, who need to document properly in order to be compliant and receive appropriate reimbursement. “Clinicians are responsible for what they document, code, and bill,” Rapsilber offered as a reminder. Additionally, timeliness of the documentation is important, as it can affect not only the quality of the treatment of the patient’s condition, but also the revenue received for the patient’s evaluation and management.

And Understand How the Playing Field is Changing

Healthcare is changing, Rapsilber noted, due to factors such as an aging population, provider shortages, telehealth, and corporatization. This means reimbursement is changing from fee-for-service models, where the payer pays the provider for each service they perform, to value-based payment, where the payer pays the provider for the care they give the patient.

Additionally, healthcare is seeing a shift from the medical model to the nursing model. The medical model is focused on illness care, while the nursing model views patient care holistically — this is value-based payment, according to Rapsilber, and it is the future of healthcare.

This means providers, coders, and billers need to pay special attention to using CPT^® Category II codes, and ICD-10-CM codes for social determinants of health (SDOH) in their documentation.

CPT^® Category II codes: Even though “the use of these codes is optional” and the codes themselves “do not have a relative value associated with them,” using them is important as the codes “facilitate data collection about the quality of care rendered by coding certain services and test results that support nationally established performance measures and that have an evidence base as contributing to quality patient care,” according to CPT^®.

ICD-10-CM SDOH Codes: Similarly, there are currently no local, state, and national-level mandates for reporting a social determinant of health (SDOH) code from Z55-Z65 (Persons with potential health hazards related to socioeconomic and psychosocial circumstances) in a patient’s chart in the outpatient setting. However, the healthcare system needs the data to help keep care cost-effective and help population health, Rapsilber’s emphasized.

Share These Takeaways With Your Practice

As different as the roles of provider, coder, and biller may be, each player in the revenue cycle has several shared goals — to deliver efficient healthcare, create better patient outcomes, and improve financial performance. This means participants in the process must listen to each other, communicate and improve education opportunities, and use technology to improve workflow and enhance data utilization, Rapsilber concluded.