We hear this a lot at Physician Coding Resource (PCR), and we understand. So many times, we as providers are resistant to learning about coding because we entered this world of medicine to help people, not reduce their symptoms and treatments to spreadsheets and numbers. The truth is, some of us are uncomfortable discussing revenue and medicine all together. And maybe in a perfect world they wouldn’t be linked, but we don’t live in a perfect world. We chose to pursue this career and now we, for better or worse, must play by the rules of the system we are in.
Our goal is not to make you into a coder. That’s a waste of time. But our medical coding training will do nothing but benefit you as a provider. Here are three reasons to understand coding.
Being audited by CMS or a private insurance company is just a matter of when, not if. You will get audited. Period. Wouldn’t it be nice to have a cursory understanding of what they will be looking for in your charts? Of course, it would. Many providers try to avoid audits by deliberately downcoding their charts as to not raise any red flags, but unfortunately, doing this is just as inappropriate as deliberately upcoding. David Doyle talks about this very thing in an article for the Healthcare Business Management Association where he says that
“Many doctors do not want to attract the scrutiny of insurance companies or auditors but fail to realize that down coding can also trigger an audit. Insurers and the government look at the frequency that doctors use one code, and when higher than normal usage is reported, they may call for an audit. (The Federal Government is concerned with improper payments, which means both underpayments and overpayments.)”
What this means is that you are damned if you do and damned if you don’t. You don’t understand coding so you deliberately bill out a lower level of service then you performed? That’s against the rules. Don’t understand coding so you bill out a higher level of service than truly performed? That’s against the rules, too. The answer is to make sure that your coding appropriately and the only way to do this is to understand some basic coding principles. Fortunately, our billing and coding classes can help.
Again, many providers don’t like to think about revenue and patient care, but unfortunately, it’s the reality we face in our current system. Estimates are that the average provider loses approximately $40,000 annually due to under coding due to improper documentation. Or another way to say this is that most providers are doing the work, taking on the risk, but they are not getting reimbursed properly for their service. That is a crazy big number. That means if you have a practice of 10 providers, your practice might be leaving upwards of $400,000 per year on the table. Just think what you could do with that revenue! What kind of improvements could you make for your team members, your patients and your time? It could really make a big difference.
We love to talk about risk at PCR. It plays a large role in determining what level of service a patient is, but for now, I want you to think about how you transfer risk in your practice. A patient comes to see you and they have a medical issue that they are concerned with. It might be a new problem, or a chronic one, or just a question they have about their health overall, but whatever it is, they are bringing you a problem and they want you to help them solve it. They are counting on you to walk them through it, solve their issue and make sure there isn’t something more serious going on. They present a certain level of risk to you and your practice. Some patients, and the nature of their presenting problems, are low risk, some are high risk, but all patients present to you with some level of risk. You then, by the nature of the patient-doctor relationship, take on this risk for the patient. You are on the line. The patient transfers that risk to you. How do you offset the risk? One way we do this is through our medical malpractice insurance, but the main way we do this is by how much we are reimbursed for the patient visit. If a patient is a high-risk patient, the 1995 Medicare guidelines say that you should be reimbursed at a higher level compared to a moderate or low risk patient. That makes sense. But here’s the thing, the only way you get paid a larger amount is if you document appropriately for that level of service. If you don’t document appropriately for coding purposes, you run the risk of under coding, or to say it another way, you run the risk of being under compensated for the risk you are taking seeing patients.
But you are taking on that risk just by seeing the patient whether you get compensated appropriately or not!
So, you might as well make sure your documentation is correct so you can be properly compensated for the risk you are taking seeing patients. Does that make sense? You are doing a risky job and need to be properly compensated to offset that risk by being reimbursed higher for riskier patients. Making sure you document appropriately for coding purposes helps you do this.
If you want to learn medical coding in order to help with audits, increase revenue and make sure you are being properly compensated for the risk you are taking seeing patients, we can help.