Chart to Check
The medical chart tells a story. If you
create the right setting and build
to a proper climax (and your coders know their job), you’ll be paid for
the work you do.
to a proper climax (and your coders know their job), you’ll be paid for
the work you do.
It’s been a long day but you have
finally completed your last chart. For each patient
you’ve seen and treated, you’ve documented the
presenting problem, obtained the patient’s history,
performed a physical examination, and recorded your diagnosis
and course of treatment. You have done your job well and you
expect to receive payment for the services you’ve
provided.
But exactly how does
that chart lead to the arrival (or absence) of a reimbursement
check in your mailbox? This is an important question because
your documentation:
• Reflects the
quality of care you provided to the patient
• Can reduce risk
and liability
• Can assist in
maximizing your reimbursement
In today’s
medical environment, care is not considered to have taken place
(and payment will not be forthcoming) until the paperwork is
done. So the life story of a chart is a good one to know.
The first stop for the
chart and accompanying forms is the hands of a medical coder.
Typically, charts are
coded either on-site by coders at the practice or facility, or
off-site by a contracted coder. If it is on-site, the coder
collects all of the documents relevant to the patient
encounter, including the physician’s documentation, which
can be recorded in various forms (i.e. template, dictation,
handwritten notes, etc.). Whatever the form, the
physician’s documentation provides a progressive picture of what happened to the patient during the encounter. The record also typically will include the patient’s demographics (i.e. name, address, social security number, insurance information, etc.), the physician’s orders, triage and nursing progress notes, and an admissions/transfer/discharge order.
physician’s documentation provides a progressive picture of what happened to the patient during the encounter. The record also typically will include the patient’s demographics (i.e. name, address, social security number, insurance information, etc.), the physician’s orders, triage and nursing progress notes, and an admissions/transfer/discharge order.
In the off-site model,
records are copied, batched, and shipped to the contracted
coder (or coding operation). Usually a batch reflects a date of
service, and each batch should contain information for all
patients seen within a 24-hour period.
When the coder
receives the records (whether on-site or off-site), he examines
them to make sure all the necessary documents are present. The
two main sets of codes to be assigned will be:
ICD-9—(International Classification of Disease),
which describes the patient’s presenting injury or
illness.
CPT—(Current
Procedural Terminology), which represents any services the
physician provided, including evaluation and management (E/M)
services, surgical procedures, diagnostics, etc.
In some instances,
physicians may elect to assign their own codes rather than
outsource to professional coders. These physicians must be
aware of the intricate documentation requirements that have to
be fulfilled in order to assure proper code assignment. An
understanding of proper coding guidelines is essential to avoid
‘over-coding’ or ‘under-coding.’
Over-coding can lead to questions of fraud and abuse or
inappropriate reimbursement, while under-coding may result in
missed reimbursement opportunities.
Evaluation and Management
How do physicians and coders know what
guidelines to follow relevant to the evaluation and management
services as represented by CPT? In an office visit or a
hospital day charge, the codes delineate the physician’s
evaluation of the problem and the subsequent management she
provided. CPT separates E/M codes by ‘site of
service,’ which can range from the doctor’s office
to the ED to the hospital.
For example, the CPT
E/M codes 99281-99285 apply strictly to services provided in
the emergency department, and reflect ranges in complexity.
Code 99281 would typically be assigned for presentations
reflective of low complexity; 99283 typically reflects moderate
complexity; and 99285 would be assigned for presentations with
high complexity. As the complexity of the case increases, so
does the level of documentation required to appropriately
support the code assignment.
Checks and balances
How can you be assured that your coders
aren’t over-coding or under-coding when it comes to E/M
assignment? CPT imposes a triangle of ‘checks and
balances’ to help ensure appropriate coding of these
services. The three key elements of an E/M service include:
• History
• Examination
• Medical
Decision Making (MDM)
The documentation
requirements for history, examination, and MDM must all be
fulfilled in order to assign the proper E/M code. Even if the
record contains pages and pages of history obtained and
examination performed, when the MDM is minimal, the chart will
not fulfill the requirements for a higher level E/M. The key is
to balance these elements so the history, examination, and MDM
match the severity of the complaint. These key elements
determine the appropriate E/M code assignment.
As coders review the
patient records, information in addition to ICD-9 and CPT code
assignment is interpreted for consideration. Coders therefore
should to be familiar with medical terminology, procedural
terminology, anatomy and physiology, pharmacology,
pathophysiology, etc. Generally, good coders have participated
in educational curricula that include these clinical subjects
and they have some records management or insurance claims
processing experience. Nurses or others with clinical
backgrounds often make good coders.
Documenting medical procedures
Complete documentation is particularly
important with regard to medical procedures. For example, in
the emergency setting, we tend to see a number of minor
surgical procedures, i.e. wound repairs, incision and drainage
of abscesses, foreign body removals, burn care, splint
applications, etc. CPT codes for wound repair vary relative to
the size of the wound, location on the body, complexity of the
repair, etc. Therefore, a detailed medical record is required
to make the proper code assignment.
A documentation
template can assist with prompts, but complete procedural notes
are highly recommended because such a note can assist in
reflecting the standard methodology and proper execution of the
procedure (i.e. in the instance of a wound repair, the
anesthetic administered, irrigation performed, explored for
foreign bodies, materials used in the repair, etc.).
Without adequate
documentation, you could find yourself defending your course of
treatment before a jury with inadequate ammunition. Or, in a
less dramatic situation, you could find that the services
you’re providing do not lead to the reimbursement to
which you might be entitled.
On to billing
Once the ICD-9 and CPT codes have been
assigned, the records usually are forwarded to a billing
department or billing company. The records then typically
progress through insurance verification, data entry, charge
posting, and electronic claims filing (to the insurance
carriers).
Payers are known to
routinely review claims and the documentation within. If they
find that the code assignment is appropriate (based on their
own coverage limitations, network provider allowances, medical
necessity, etc.), the claim is approved for payment and they
will send you a check.
If payment is not
approved, you will receive a notice of denial, which may be
tied to inaccurate coding. Two very common reasons for denial
are:
• Insufficient
support of a CPT code by an ICD-9 code
• The use of
outdated ICD-9 and/or CPT codes.
It is a coder’s
goal to appropriately reflect the medical necessity for a CPT
(services) code through the assignment of an appropriate ICD-9
(descriptor) code. For example, a wound repair (CPT) procedure
code would need to be supported by a wound descriptor (ICD-9)
code; or an EKG (CPT) code would need to be supported by a
cardiac (ICD-9 code). You are likely to experience denials if
the services you are submitting for reimbursement are not
supported by correlating descriptor codes.
I strongly suggest
that coders keep resource materials published for the current
year rather than using references that are several years old.
Because ICD-9 and CPT codes are constantly being created,
revised, and deleted, you are likely to experience numerous
denials if you are using 2001 ICD-9 and CPT books for 2004
claims.
There are ICD-9
(descriptor) codes for every illness, injury, or presenting
problem one could imagine, plus CPT (services) codes for any
type of evaluation and management service, all diagnostic
services and surgical procedures performed by medical
professionals. Awareness of changes and updates plus the
pursuit of continuing education are the responsibilities of a
good coder.
Remember, coding is a
moving target. It’s in your best interest to ensure that
your coder:
• Has received
proper training and perhaps even certification from a
nationally recognized, professional coding organization. Two of
the most widely known such organizations are the American Health
Information Management Association (AHIMA), which offers the CCS (Certified Coding
Specialist), and the American Academy of Professional Coders (AAPC), offering the CPC (Certified
Procedural Coder) and the CP-H (Certified Procedural
Coder—Hospital Based).
• Participates in
continuing education.
• Participates in
professional chart reviews for quality assurance.
While documentation
requirements can be frustrating, providing complete patient
documentation to your coder will serve you well in your medical
career. The story of your success as a physician is bound up in
the story of the charts you create—you want both to have
a happy ending. g
Tracie M. Christian, BS, CPC, CCS-P, is
the vice president of coding, technical and training services
for
ProCode, Inc., a Dallas, Texas affiliate of The Schumacher Group, a national emergency medicine
management firm based in Lafayette, Louisiana. She can be reached at tracie_christian@procode-inc.com.
ProCode, Inc., a Dallas, Texas affiliate of The Schumacher Group, a national emergency medicine
management firm based in Lafayette, Louisiana. She can be reached at tracie_christian@procode-inc.com.
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