6 steps to better coding

The doctors in the Louisiana multispecialty group were stunned when they examined their accountant's report. Over the past year, each doctor had managed to bring in more than $25,000 in additional billings-without adding patients, services, or staff.

The windfall was simply the result of proper coding, explains Susan Reese, a coding consultant at MedaPhase in San Antonio. Undercoding-especially on E&M codes-is all too common. Doctors tend to "play it safe" by coding all visits 99212 or 99213, when, in reality, many office visits are level 4 or even level 5. Assuming a 99214 pays approximately $30 more than a 99213, and the typical doctor undercodes three visits a day, that's about $90 per day per doctor in lost earnings.

Why do doctors undercode? Some may not know the rules. Others may be too rushed. But most doctors say they drop a level to "stay in a safe coding zone" and avoid government scrutiny. Practice management experts have long suspected that undercoding is a widespread problem, and now a recent study offers proof. The study ("How Many Problems Do Family Physicians Manage at Each Encounter? A WReN Study," Beasley JW, Hankey TH, Erickson R, et al., Annals of Family Medicine, 2004;2:405-410), which looked at 29 family physicians and 572 patient visits, found that while physicians managed an average of 3.05problems per visit, they recorded only 2.82 in the chart and even feweron the bill-just 1.97.

In short, doctors undercode, underbill, and cheat themselves out of revenue due them.

So how can you stop shortchanging yourself? We asked consultants for their advice. Here are six steps they say are critical.

1. Don't sell yourself short. "Doctors tend to rationalize, 'I didn't spend much time with that patient' or 'I deal with hypertension all the time, so it's easy for me,'" says Reese. "Doctors don't realize that coding levels have little to do with how quickly or easily they come up with a plan of care."

"You can spend only 10 minutes with a patient and still determine the plan of care," explains Carol Pohlig, senior coding specialist for the office of clinical documentation at the University of Pennsylvania Medical Center in Philadelphia. "What weighs in is the effort and risk involved in executing and implementing that plan of care."

"Doctors are sometimes already up to a level 3 visit before they even touch the patient who has chronic diseases in addition to a chief complaint," says C. Nancy Noonan, a consultant from Yellow Springs, OH. For example, say a hypertensive, insulin-dependent diabetic presents with a troublesome cough. You see that the vitals and glucose reading are within normal limits, so treatment for HTN and diabetes requires no adjustment. You examine the patient and note in the chart a diagnosis of an upper respiratory infection. You don't think to document that you've made a considered decision not to change his regimen.

In fact, nontreatment is part of medical decision making, says Noonan. That visit could legitimately have been coded 99214, but instead, it will get a 99213.

2. Establish the purpose of the visit up front. Your hand is on the doorknob, you've already noted the complexity of the office visit, but now your patient says to you, "Oh, by the way, would you mind looking at . . . ." You've just been ambushed into a lengthy exam or counseling session. Afterward, you're even further behind your schedule-there's certainly no time to redo your documentation or figure out the level of this visit. So you take the easiest route and code midway between a minimal visit and a complex one.