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Staring down at the new MDM chart, I asked the profee (professional fee) auditor, “If I think it’s severe, do I need to explicitly document that or will it be obvious by the problem?”

“You don’t need to state it as severe,” she told me.

She audited my charts. She agreed with 19 of 20 of my codes. The one she disagreed with?

I had dropped my code based on a severe problem but didn’t specifically document it. She did not think the problem was severe.

So, she confirmed my question. I do need to state it as severe.

There’s one consistent theme that comes up every time I teach or discuss the MDM chart and professional coding with physicians: disagreements between the thought process of physicians versus coders.

Coders are not physicians.
Physicians are not coders.
Yet, the system we’ve found ourselves in requires a marriage that at times seems to have irreconcilable differences. But there’s hope for this relationship yet and it boils down to… clear communication.

Professional Coding Arrangements

For physicians reading this who might be confused, there are typically 3 different types of arrangements between physicians and their professional coding.

1. Physician self-coding where the physician selects the CPT (and ICD-10-CM) codes themselves. While, yes, you’ll “get the RVUs you expect,” this puts you at risk of undercoding or overcoding as well as missing complex coding nuances such as modifiers. Physicians in this set-up should pay for frequent audits.

2. Coder review and reconciliation where the physician drops the code themselves, but a coder comes behind them and reviews documentation to ensure that code is supported. If not, the code is changed. Depending on the arrangement, the physician may be made aware of that code change for debate, or deference may be given to the coders. While this process may result in higher accuracy and allows quality assurance by the physicians, it could also be time-consuming and significantly delay claim submission and payment.

3. Full outsourced coding where the physician does not drop a code and coders code based on the documentation. This allows physicians to focus on care and documentation, not coding. This decreases your risk of fraud as, ideally, only codes that are supported by the documentation are submitted without any outside influence. But, quality varies between vendors and you may even have to a get a third party vendor to audit the coding company from time to time.

Bridging the gap

So, what’s the problem?

First, when discussing disagreements with physicians, physicians have told me they “felt” that a visit deserved a level 5 (99205, 99215, etc.). After hearing what they did, they are often correct in that “feeling” but… the documentation didn’t support it. Remember, this isn’t just about getting paid, but for protecting yourself if The Feds ever show up to your clinic. They won’t care what you said you did, they’ll only care about what the documentation shows.

Second, and the most frequent, is assumptions made by physicians that either a coder is not allowed to make or is subtly suggested in documentation.

Example: A hand surgeon sees a patient for follow up of a fracture of a pointer finger. The word “stable” is used frequently throughout documentation. The physician codes a 99214 based on a moderate level problem. However, the coder disagrees and suggests documentation only supports a low-level problem as a stable acute illness / uncomplicated injury and should be coded as a 99213. This was sent to an auditor, who agreed with the coder. This was then sent to me.

I noticed that documentation included evaluation of capillary-refill and sensation distal to the fracture. As the problem primarily involved the bone but assessment required evaluation of “body systems not directly part of the injured organ” (i.e. vasculature and peripheral nervous system), I concluded the problem met the definition of an “Acute, complicated injury”(see page 15). However, I didn’t fault the coder for not coming to that same conclusion.

Examples like that come up over and over and over again. I remind physicians that not only are coders not allowed to infer to determine the level of severity (nor have the background to determine if a limb is at risk of permanent injury), but they are also held to their own productivity standards. I spent way more time reviewing that chart than that coder was probably allowed. While that’s not ideal, it is simply reality. And, unless you’re going to change your arrangement to one of the other two types mentioned above, the problem will occur again (and frequently).

So, my marriage counseling:

Clear Communication

Learn the MDM chart (my version above) and know the buzzwords.
Create dot phrases / smart phrases (or whatever your EMR supports) that includes those buzzwords.
Put that somewhere near your A&P ( I’ve written about this before as the “billing timeout.”). Then, bam, you get the RVUs you expect and you make it black/white for the coder and they efficiently agree with your coding.

Example: If you’re a hand surgeon frequently taking care of finger fractures and the initial visits require assessment of the neurovasculature, then make a dot phrase that inserts, “Closed displaced transverse fracture of a phalanx is an acute complicated injury as it required evaluation of body systems not directly part of the injured organ.”

BUT, remember, you’re not documenting that so that you can bill higher, you’re documenting that so your documentation clearly reflects what you actually did and that can be converted to the appropriate code.

Clear communication. Happy Marriage.
Send me postcards from the honeymoon.

That’s all for now. Don’t hesitate to ask questions as they help inspire future issues!

Cheers,

Robert

Thanks to Kristi Knight, CPC CPPM for editing this newsletter!

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