Why & How to Teach Coding to Residents Alex Wilgus, MD Fellow, Faculty Development Program University of Virginia School of Medicine, Department of FM Faculty, Director of Patient Care Lynchburg Family Medicine Residency Program Lynchburg, VA

Plan Utility of learning to code Utility of learning to code Challenges, barriers Challenges, barriers How to address these challenges How to address these challenges General discussion, idea exchange General discussion, idea exchange This is not an historical lecture, or a gripe session This is not an historical lecture, or a gripe session Resolved: We have a dysfunctional documentation requirement, for which there is tremendous inertia for change Resolved: We have a dysfunctional documentation requirement, for which there is tremendous inertia for change

Question…. How many of you (or of your departments/residencies) have all the money you need to fulfill your mission?

A Solution… One FM residency, with intensive coding education, saw a net Medicare payer increase of $9459 for about 1000 encounters One FM residency, with intensive coding education, saw a net Medicare payer increase of $9459 for about 1000 encounters The new charge “profile” would have generated for them $457K in one year for 26,500 established patient visits! The new charge “profile” would have generated for them $457K in one year for 26,500 established patient visits! Rowe J, Fagan B, et al. The value of a coding education. Fam Pract Manag Mar;12(3):20, 22.

One Program’s Results…

The Problem: Medicare requires adherence to documentation guidelines (DGs) for payment Medicare requires adherence to documentation guidelines (DGs) for payment Family physicians don’t document all they do in a clinical encounter; therefore, Family physicians don’t document all they do in a clinical encounter; therefore, They can’t charge appropriately, for fear of audits, and fraud investigations. They can’t charge appropriately, for fear of audits, and fraud investigations. "Physicians have been conditioned to downcode, in part, because documentation under the guidelines is too cumbersome, and there is a strong 'fear factor' " "Physicians have been conditioned to downcode, in part, because documentation under the guidelines is too cumbersome, and there is a strong 'fear factor' " Glendinning D. “Medicare Zeroes in on E&M Coding…” American Medical News; Jan 3/10, 2005.

Motivation: What Happens with Improper Coding You lose money You lose money You are always at risk for audits, and may be fined, if documentation is lacking You are always at risk for audits, and may be fined, if documentation is lacking "Even if a doctor has others working for him/her—staff coders or a billing company— s/he's the one ultimately responsible for coding decisions." "Even if a doctor has others working for him/her—staff coders or a billing company— s/he's the one ultimately responsible for coding decisions." You have to work harder and longer to make your living You have to work harder and longer to make your living Dorothy Pennachio. Code with care: You're being watched. Medical Economics May 7, 2004;81:26.

Barrier Resident/faculty apathy Resident/faculty apathy Solution: Solution: Constant reminder of the financial/legal ramifications of improper coding Constant reminder of the financial/legal ramifications of improper coding

Incremental Payment (Medicare)

Barrier Knowledge deficits Knowledge deficits Solution: Solution: Frequent, short didactics, with examples Frequent, short didactics, with examples Integration of coding “tutorials” into precepting Integration of coding “tutorials” into precepting Individualized profiling of coding patterns against a ‘norm’ Individualized profiling of coding patterns against a ‘norm’ Concentrate on “established” visits Concentrate on “established” visits

Example of “Coding Profile”

Barrier Lack of institutional support Lack of institutional support Solution: Solution: Reminder of the financial ramifications Reminder of the financial ramifications Part-time coding expert Part-time coding expert Chart audits Chart audits Individualized feedback for mis-coding Individualized feedback for mis-coding

Barrier Complex documentation guidelines Complex documentation guidelines Solution: Solution: Coding pearls/shortcuts Coding pearls/shortcuts PDA coders PDA coders Pocket cards/cheat sheets Pocket cards/cheat sheets

Coding Pearl Examples Medication hx is considered a PMH component Medication hx is considered a PMH component Medication Rx is considered moderate-risk medical decision making (MDM) Medication Rx is considered moderate-risk medical decision making (MDM) Three chronic medical problems in an encounter essentially guarantees a level 4 visit Three chronic medical problems in an encounter essentially guarantees a level 4 visit Only 2 of 3 visit components are needed for established office visits Only 2 of 3 visit components are needed for established office visits Time alone can determine charges Time alone can determine charges

Coding Pearls… Henley DE. Coding better for better reimbursement. Fam Pract Manag Jan;10(1):29-35.

Pocket Cards

Handheld Programs E&M DocuMentor E&M DocuMentor topsE&M Coder topsE&M Coder ZapCode ZapCode STAT E&M Coder STAT E&M Coder Inforetriever Inforetriever

E&M Coder

Recap Have someone who knows the details of coding well & can teach it Have someone who knows the details of coding well & can teach it Ins & outs, shortcuts, residency issues Ins & outs, shortcuts, residency issues Regular chart audits with individual feedback are a must Regular chart audits with individual feedback are a must Recognize that it is an illogical game Recognize that it is an illogical game An attempt to quantify the work of an exceedingly complex encounter An attempt to quantify the work of an exceedingly complex encounter Understanding of the onerous nature of Medicare coding requirements may help the cause. Understanding of the onerous nature of Medicare coding requirements may help the cause.

Other thoughts… This set of slides, copies of tables for pocket cards, links to documentation guidelines can be found on website

References 1. Henley DE. Coding better for better reimbursement. Fam Pract Manag Jan;10(1): Rowe J, Fagan B, et al. The value of a coding education. Fam Pract Manag Mar;12(3):20, Nicoletti B. Are You Coding Accurately? Fam Pract Manag Jun;11(6): Documentation Guidelines: Glendinning D. “Medicare Zeroes in on E&M Coding…” American Medical News; Jan 3/10, Robert Lowes. Is your coding on target? Medical Economics Dec. 5, 2003;80: Dorothy Pennachio. Code with care: You're being watched. Medical Economics May 7, 2004;81: Teaching Physicians: or Brochure pdf or Brochure pdf Brochure pdf Brochure pdf