Have you ever played the board game "Clue" by Parker Brothers? You have to figure out who did what to whom, where, and with what. Oh, and be right of course! Well, proper coding is like a game of Clue. Coders and billers need to find out what the physicians did with whom, where, with what, and how they reasoned out their solution that way. Moreover, if someone else comes knocking at your door wanting to know the reasoning, you need to have everything properly documented and accessible, so that anyone might be able to solve the same game from all of the clues, in the same way. It can be the difference between game success and game over.
In all of the history of mankind, doers do and recorders record. If a woman (or man) conquered the world, but no one was there to write it down for anyone else to know about it, did they actually do anything? By definition, "history" begins with written records. The doer and the recorder are each others’ right-hand. How legitimate is one without the other? This principle applies to your office as well.
Coders/Billers (sometimes the coding position in an office is that of biller) and Physicians should be working hand in hand to get the coding in your office done right.
It "matters" a lot!
- If you want to provide the best patient care, you need to document everything like a careful scientist, so that you can help them now and in the future, it matters.
- If you want to be compliant and not worry about audits or money recalls, it matters.
- If you want to get paid, it matters.
To be compliant and ethical, coders can only code to the condition/diagnosis/procedure as it is clearly documented by the physician. This includes no "assumption coding" on the coders part. (i.e. Because the patient was in for a certain condition last week and there is a test result back that often means something.) The coder cannot make the leap about the relationship, indications, or contraindications; those must be made by the physician alone and documented by him/her appropriately). If there is insufficient data, or relational interpretation is not present, the coder has the option to query the physician (more about this later). The coder’s position should be just like the police officers on old TV show Dragnet, "Just the facts, ma'am."
Can you begin to see the relational rationale behind my thoughts that physicians and coders should truly be hand-in-hand?
"We don't get paid for that."
Oh yeah, who said so, when, what were the exact circumstances?
If you cannot answer these questions, you are certainly not a Clue hound. Just because you were rejected for something once, doesn't mean that it is the final judgement call for every payer.
Think Clue:
- What was the exact rejection?
- Was everything on your part coded correctly for what they wanted?
- What insurance company rejected it? Have they paid for it before? What was different this time? Did you call and ask them about it?
- Was the service or procedure covered by the patient's plan?
After you've covered all of the basics, document it for future reference. Keep a Clue book for yourself. Document your clues each time, until you can find the pattern that gets you paid. It may be true that Medicare never pays for it, but it may be equally true that Blue Cross, Aetna, HAP, etc. do. How much money could you lose out on by assuming "we don't get paid for that." And now, if you tell someone Medicare never pays for it, you'll be able to show them why.
To query or not to query?
That is the question.
What if you find that you are not holding all of the cards? What if someone has not given you all the clues? Well, you'll have to ask! The proper term is "query" as in "to ask or inquire" of the physician.
Now there was some question back in 2001 from Medicare if query documentation for DRG (diagnosis related groups) validation was acceptable. At first CMS said "No", but then shortly thereafter changed its mind. Query forms can be both important and valid. In a query you reference what you have a question on, or about what may be missing, and the physician responds back with appropriate answers so that the visit can be coded correctly. Simple huh? Ask, receive, code, and then receive payment.... of course it can never be THAT easy.
Things to watch out for and be concerned about include:
This is official documentation so it shouldn't be on a scrap of paper, it shouldn't just be an "off the cuff" askance of the physician, and it shouldn't be via e-mail. A proper query will be on a hard copy form that can then be added into the patient's file for that visit, as official documentation. Optimally, the physician would not only answer the query, but use it as a check, to go back in and make an "official append" to his information in the system about it (i.e. in the EMR or practice management notes that he/she documents and maintains).
Leading and misleading the physician. Remember the coder's laws from above, they apply here. Whether intentionally or unintentionally the coder should not be "leading the physician" or “assumption coding", this should truly be a "just the facts" query.
Example-
Leading: "Did the patient have X with Y, if so Medicare pays $1200 for the procedure, can you please document this in the patient notes." Now you've got the physician possibly thinking two different things- "did I forget something" or "$1200 is better than $350, I need to fix my documentation so it can be billed out for $1200". Simply wrong, what more can I say?
Example-
Assumption: "I noticed that the patient had X last week when I coded their visit. If they are still taking Z can you please note X with Z for this visit." The Z the patient is taking this week may have nothing to do with their visit for X last week, and neither X nor Z may have anything to do with today's visit. You cannot assume documentation or a connection, it simply may not exist. Even if it does, it is the physician's call not the coder's (doer vs. recorder).
You may not be intending to do either of these things, but you must watch out for both. Coders, you are recorders of history, not creative writers, just don't go there. That all being said, sometimes there is very specific information that the coder NEEDS to know to code and bill out the physician's work correctly. This is where each right hand has to have a sound hand shake with the other; some would call it a working partnership. Back to your Clue book, have you noticed that there are procedures that come up for query "all the time". Maybe you need to work together to have certain things in your office run a bit more automatically. Some codes are more specific and complicated in what needs to be documented for payment.
Example-
Laceration Repairs: You need to document the location, length, and depth to code them properly. I do not believe anyone would consider it leading or assuming if you ask "please note the location, length, and depth for each laceration repair".
If your physicians stitch a lot of things up, then it may be advantageous to add "sub" procedure fields on your route slips for them to fill in specifics like this, or you may want to attach a "laceration query" to the route slip with the patient for them, so that in their haste to stitch someone up, they don't forget to document the specifics. Many times something like this can be added into your EMR program so that the physician can check a few boxes as they interview and examine the patient, and you have instant, complete, compliant documentation.
Physicians, coders are NOT the coding police. They are your partners in documentation and getting paid.
Coders, physicians are NOT aggressive conquerors who in their rush to move forward roll over all obstacles and bumps. They are your partners in history and getting paid.
If it isn't written, it doesn't exist. So don't just be a doer of great deeds, be a recorder of them also. Get a clue, and don't just "do stuff", make history!
For More Information:
Physicians Practice "America's Leading Practice Management Journal” online at www.physicianspractice.com This is one of my Editor's choice websites. I subscribe to their "Physicians Practice Pearls- Coding" e-newsletter (amongst other things), and I recommend them as a great office resource.
For the Record "Committed to Enhancing the Health Information Profession" at www.fortherecordmag.com and for this article I refer back to the January 7, 2008 article "The Query Quagmire"
Another Editor's choice for "a great office resource".
American Academy for Professional Coders (AAPC) at http://www.aapc.com/
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