Streamlining Documentation and Coding of the Well Woman Exam (WWE) Catherine Scarbrough, M.D., John Adams, M.D., Mary Margaret Clapp, M.D., Katie Gates, M.D., Ambreen Mardhani, M.D., Maury Minton, M.D., Melanie Tucker, Ph.D. University of Alabama Family Medicine Residency Program Tuscaloosa, AL

Background A Well Woman Exam (WWE) is an annual preventive screening for gynecological diseases and can include a breast and pelvic exam. Coding and billing for these exams is complex. Medicare, Medicaid, and private insurance carriers require different diagnosis codes. There are different pap collection fee codes for the different carriers. If a visit is incorrectly coded, reimbursement may be denied or delayed by insurance carriers.

Not A New Problem “When you perform a well-woman exam, you could have trouble getting paid for the visit if you don’t know how to properly code Pap tests, and if you don’t understand how Medicare and private payers’ guidelines differ.” -Medical Economics; Oct 7, 2005

Importance Reason Percent Diabetes Mellitus 2.8 Gyn Exam 1.8 Hypertension 1.1 Fever 0.9 Back Symptoms 1.0 20 Leading Principal Reasons For Outpatient Visits: CDC/NCHS National Hospital Ambulatory Medical Care Survey, 2010

Expected Source of Payment Importance Expected Source of Payment Percent Medicaid 42.9 Private Insurance 36.4 Medicare 10.8 No Insurance 7.5 Other 8.6 Preventive Care Outpatient Visits Expected Sources of Payment: CDC/NCHS National Hospital Ambulatory Medical Care Survey, 2010

Importance Large number of WWE’s per year by family medicine physicians Lost revenue Increased expenses Denials and re-submitting claims = increased workload on billing departments

Could rates be improved through resident education/training?

A Potential Solution

Study purpose Determine whether the use of a concise, single-page coding reference improves reimbursement rates for well woman exams (WWEs) at the University Medical Center (UMC). Hypothesis: the availability of a reference card that instructs resident physicians in proper coding of WWEs will result in better reimbursement rates at UMC.

Methods Data mining by the business office Reference tool created Educational session performed After 6 months, data mining run again 1. Data mining: performed by the business office to determine the number of WWEs performed in a six-month period at UMC, as well as the dollar amount billed for the exams and whether or not the claims were denied. 2. Reference tool: created that provided proper visit codes, pap collection codes, and correct EHR templates to be used for WWEs, organized according to different insurance carriers. 3. Educational session: performed for residents, attendings, nurses, and other staff from the Family Medicine and OBGYN clinics. 4. After using the reference resource for 6 months, the reimbursement/denial rate report was run again and compared to initial data to determine if reimbursement rates are improved and claims denials are decreased.

Postintervention March-Oct 2015 Results Preintervention 2013-2014 Postintervention March-Oct 2015 Pap smears performed 817 127 Appealed by insurance due to documentation 714 3 % Denials Due to Documentation 87% 2%

Postintervention March-Oct 2015 Results Preintervention 2013-2014 Postintervention March-Oct 2015 % Denials Due to Documentation 87% 2% Lost Revenue $21,470 $231.81

Study Limitations Modifier acceptance per insurance carrier changed Missed educational opportunities Some residents not aware Reference tool handouts “lost” during construction in preceptor room OBGYN faculty Changing targets per guidelines Study crossed academic year Study crossed ICD-10 implementation

Topics for Further Study Nature of claim denials How our claims denial rate compares with other parts of the country Means of improving teaching tools for coding

References No authors listed. Well Woman Exam. Med Econ 2007 Feb 16; 84(4):18-9 As-Sanie S, Zolnoun D, Wechter ME, Lamru G, Tu F, Steege J. Teaching residents coding and documentation: effectiveness of a problem-oriented approach. Am J Obstet Gynecol. 2005 Nov, 193(5):1790-3 Skelly KS, Berqus GR. Does structured audit and feedback improve the accuracy of residents’ CPT E&M coding of clinic visits? Fam Med 2010 Oct, 42(9):648-52 CDC/NCHS National Hospital Medical Care Survey, 2010

Questions? Thank You!