July 22, 2010 – 7:50 am
By Robert Redling
Coding can be a dense and Byzantine process. Doctors hate it. The worst of it is that every payer seems to have its own take on coding.
But you can’t bill for services without coding for them. And as Medicare’s pay-for-performance program catches on and private payers follow, correct coding and documentation are more important than ever.
Bottom line: If you want to get paid correctly for the work that you do, you must understand the rules.
We turned to several procedural coding professionals — experts who advise physicians, medical practices, hospitals, and other providers — and asked two questions:
First, what are physicians doing most often to undermine their own coding and documentation efforts? In response, our experts offered nine big coding blunders that physicians could and should fix today.
“I see many physicians stuck in the mind-set that what they learned about coding 10 years ago is all they need to know,” says Rhonda Buckholtz, vice president of business and member development for the American Academy of Professional Coders. “A lot of times their knowledge of coding is outdated.”
Second, we asked them to describe the emerging trends and possible coding rule-changes likely to affect physicians’ lives in the future. (See textbox “Trends.”)
Straight from the experts, then, here are the tips, peeves, and predictions we heard most often.
1. Failing to note negatives
There’s far more to assessing a patient than listing the chief complaint. Noting the pertinent negative findings — ruling out what’s not involved — is a fundamental part of the diagnostic process. So why not get paid for it? Unfortunately, physicians can slip up when documenting this aspect of their thought process, says Margie Scalley Vaught, a coding consultant based in Chehalis, Wash.
“To give the proper CPT code for the office visit, it comes down to what did you touch and what was the result,” Vaught says. “If you leave out some of the negatives you could end up with a lower-coded visit even though you spent the time and did perform an exam that deserved the higher code.” Read the rest of this entry »
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Everyone knows that in a medical office the phone is a critical element in delivering quality patient care. Making appointments, scheduling diagnostic studies, making referrals, and reporting test results to patients . . . it’s all done over the phone – a tool too important not to take seriously. Here are a few tips on making the phone work for you, and for your patients.
