A practical guide to striking a coding balance between physicians and coders
Should physicians assign their own codes?
It started with the EHR boom
The adoption of electronic health records (EHR) significantly changed the workflow in today’s physician practices. One major difference is the way in which physicians select evaluation and management (E/M), CPT® and ICD codes. Rather than circle a code on a paper charge sheet, physicians now choose a code from a drop-down menu in the EHR.
In many cases, electronic code selection saves money and streamlines the revenue cycle. Although these efficiencies are beneficial, practices still need to monitor the accuracy of the codes they assign. Without continual monitoring, practices could experience the negative consequences of decreased revenue and an increase in denials and audits.
The risks of physician-assigned codes
Although practices gain efficiencies and reduce costs when physicians assign their own codes, there are also several potential pitfalls to this process.
General audit risk
When physicians assign their own codes without additional internal review, they may be at risk for an external audit. If a provider fails an audit, it takes the focus off providing patient care and places it on fighting the recoupment as well as bracing for the cost of legal support.
Denials due to undercoding
As physicians navigate the complex medical coding system, they may intentionally undercode their services to avoid payer and auditor scrutiny. However, doing so means that physicians could also miss out on significant reimbursement to which they’re entitled. Approximately 15 percent of claims are undercoded, costing physicians an average of approximately $23,000 in missed revenue annually.¹
Denials due to overcoding
Because payers tend to monitor providers who consistently bill higher level E/M codes, overcoding these services can present significant compliance risk for those physicians.² Primary care physicians overcode or underdocument 27 percent of submitted claims, putting $41,000 of annual revenue at risk for an audit.¹
If the federal government suspects overcoding or undercoding, it may audit a provider and fine him or her up to $10,000 per line item.³
¹Source: Advancing the Business of Healthcare
²Source: JD Supra
³Source: The Health Law Firm
It’s true that technology reduces the need for additional staff.
However, physicians spend approximately 74 percent of their time completing tasks in the EHR and performing other administrative work.
They spend only 26 percent of their time providing direct patient care.
Physicians routinely request feedback about their coding and documentation. However, when they assign their own codes, there is no feedback loop. By the time they hire an auditor to provide this information, the patient encounter is a distant memory.
The benefits of hiring a medical coder
Hiring a certified medical coder can bring many benefits to your organization, including the following
Increased accuracy and compliance
Certified medical coders understand coding guidelines, and they know what it takes to ensure accurate payment and avoid denials.
Reduced need for internal audits
Certified medical coders can oversee the entire internal audit process using automated tools that increase efficiency and avoid the need to select cases manually.
Fewer missed charges
Certified medical coders can more easily capture all relevant charges, resulting in a positive impact on revenue. Coders can also ensure that physicians report all relevant CPT codes as well as any and all diagnosis codes to establish medical necessity.
Reduced risk of overcoding and undercoding
Certified medical coders minimize compliance risk by assigning accurate codes.
Ability to regain the focus on direct patient care
Sixty percent of more than 17,000 physicians say that their EHR detracts from patient care. However, by focusing on accurate and complete documentation, physicians inherently provide better patient care.
Reduce denials, increased reimbursment
Studies show that approximately nine percent of claims, on average, require rework. At an average cost of $25 per reworked claim, physicians can save thousands of dollars in revenue each month by simply focusing on compliant coding.
Strike a balance
Practices using an EHR must ultimately answer this question—will physicians or coders assign codes? Many experts believe that coding should be a shared responsibility, as this model has been proven to decrease coding backlogs and increase coding accuracy.
An appropriate blend of technology and coders could be the right solution for many medical groups. As providers consider whether to hire a certified professional coder or to bring someone into the practice to audit periodically, they must determine whether the services are worth the cost. Many organizations use computer-assisted coding, for example, to achieve its compliance goals with far fewer in-house coders and a reduced need to rely on outsourced coders as well.