Orthopedic Coding Alert

Problem: Physicians and mid-level providers, scurrying to stay within a reasonable time table of their schedule, are often tardy as the ever-increasing administrative burdens of prior authorizations, referrals, pharmacy clarifications or substitution requests, "quick phone calls" to the hospital, or curbside consults continue to mount.

Add to this a paltry reimbursement structure with the two-steps-forward, one-step-back federal reimbursement scheme, and providers are finding it ever more problematic to see enough patients to maintain cash flow.

Solution: The key under such pressures is accurate coding -- both diagnostic (ICD-9) and therapeutic (CPT).

The signature line of the CMS-1500 form clearly states that the provider is liable for billing done by himself or a designee in all of the following ways:

--personally

--financially

--civilly

--criminally.

But many providers may still appear to see "interruptions" regarding proper coding as a nuisance. Instead, they should see it as a time for clarification, optimizing reimbursement with correct coding and keeping them out of trouble. They should appreciate the clarification because the providers ultimately are responsible for the codes billed.

Also, providers should direct which ICD-9 and CPT codes are submitted because they can most accurately and specifically depict what occurred in the clinical encounter. Here's why: The coder was not there, and regardless of his level of expertise, he often needs assistance when confusion exists surrounding a code. The doctor is responsible for providing this clarification.

Approaching the physician should be a collaborative, unimpeded and open-ended process because both parties -- the coders and the providers -- are tying to achieve the same result: accurate coding.

Consider this: The coder sometimes needs to point out the lack of an open communication channel because many physicians may feel threatened or anxious discussing CPT and/or ICD-9 codes. Coding may be an area in which they have little expertise. Saying, "I don't know," although important in medicine, is often not part of a provider's vernacular. Moreover, many of us don't like to admit we are wrong.

To make the most of your conversation, plan ahead. Simply having a conversation at the right time may be all you need to do.

Don-t: Do not attempt this verbal exchange when the doctor has just been up all night on-call.

Don-t: Do not try the conversation when the doctor has just had one of his more histrionic or high-maintenance patients.

Don-t: You should avoid trying to have this conversation in the middle of clinical hours when everyone and everything is running late. Timing is everything, and this is no exception.

Do: Be pre-emptive -- bring up the topic at an office meeting. This is a good idea so the providers know you are not trying to tell them how to do their job. You simply want to help them capture the encounter from an alphanumeric perspective that the insurer will understand.

Tip: Weekly office meetings with staff and providers often help to clear the air by not allowing an issue to fester. These meetings are usually shorter, too, as little time has passed since the previous meeting. Weekly or twice-monthly meetings allow more immediate feedback on changes implemented from the last meeting.

Do: Another angle to broach the subject of correct coding is to address payment. Explaining that inaccurate coding could slow down a claim that otherwise insurers would have paid promptly might make the difference. (You might need to expand on the clean-claim concept, too.) Remember: Money talks. Inaccurate coding will affect the practice's bottom line, and regardless of the protests, the buck stops with the doctors.

Tip: Doctors should know that some managed-care products monitor ICD-9 complexity against reported E/M codes simply to determine if there was enough medical complexity to justify a higher-level E/M code. (Remember, you must use five-digit ICD-9 codes where appropriate and applicable.) Only the providers can accurately determine the diagnosis or symptom, and that is why you are asking them to clarify matters.

Do: If financial and administrative optimization fails to encourage them, having a frank discussion about the need for better communication due to the potential risk it poses to the practice in the event of an audit would be helpful.

Do: If approaching your doctor as noted above still doesn't work, enlisting the office manager to sit down with you and the provider might be another option.

Bottom line: Regardless of which approach you choose, being direct, pragmatic and finding the best time to approach the provider will allow for a more seamless transition from clinical encounter through claim submission and prompt adjudication. If your doctors won't listen, let them read this piece -- arguing is hard when he is reading what could be an autobiographical account of how he interacts (or doesn-t) with his own staff.