BMN Blog

SEP 14
Physician Workflow and Coding Specificity- The Effect on Value

It has now been two years since the implementation of ICD-10, everyone survived! While denials have been minimal, the goal of implementing ICD 10 to acquire more specificity and a complete picture of health has not been fully achieved.  Physicians and managers have created a new set of shortcuts to assure payment of claims, relying on paper superbills or inappropriate conversions from ICD 9 to ICD 10.


Physician or provider workflows are essential to coding correctly and specifically. Paper cheat sheets or superbills greatly restrict the code selection available during a visit.  Simply writing words to describe disease systems will cause you to leave money on the table when coding multiple comorbidities.  Many physicians utilize the drop down selection of codes in the EMR while seeing patients in the office, but while rounding on their sickest patients in the hospital, they use handwritten descriptions resulting in non-specific coding.  During a hospital stay, a patient may present with abdominal pain, and then receive a diagnosis such as, appendicitis.  If complications arise, sepsis then abscess could also occur, this patient’s coding pattern should reflect the growing intensity of the illness to include the organism causing the complications.


Many EMR’s offer mobile applications to access office records during hospital rounding and offer a drop down list for specificity in coding. If the physician does not have this option, there are rounding software applications utilized by physicians or groups who see a large volume of patients in the hospital or long-term care setting.  The rounding software allows for messaging between physicians in a group, allows for easy transition when changing on-call assignments, and assures charge capture for each encounter.


Most insurance companies have placed a great deal of important on HCC codes, or Hierarchical Condition Codes. Under the HCC system, physicians are paid more for providing care to patients with certain chronic conditions and problems.  The Merit Based Incentive Program for 2017 is a flexible program, the Cost category will be zero, but cost is proposed to be 10% of the total score in 2018.  In 2019, the Cost category is projected to be 30% of the total MIPS score allowing some time for physicians/providers to improve documentation and coding.  Some specialty groups are seeking refuge by considering a MIPS Accountable Care Organization in 2018 because ACO’s will not be scrutinized for the Cost category, and most specialists will only report Advancing Care Information.  Eventually, the MIPS ACOs will be transitioned to a Track 1 ACO causing them to bare risks.  If the physicians want to exit the ACO at that point and go it alone, they will have much work ahead of them to improve coding and documentation.  Specialists would have little experience submitting quality information due to primary care physicians having led the effort for the Quality category in the ACO.


Some insurance carriers are doing a great job of educating providers and billing/ coding staff in proper coding. Many practices have been scrutinized through chart review, a mechanism used by the insurance carrier to pull HCC codes from documented notes. If you want to stop being scrutinized, improve documentation and code efficiently.  It is important to internally audit charts to improve coding and educate providers. It is always best to code procedures and surgeries from the documented notes as opposed to utilizing codes submitted by the physician.  If staff are not trained on procedure and surgical coding, consider seeking assistance from a certified coder who has expertise in the specialty or sending staff to a conference for specific coding education.


Healthcare is rapidly changing, administrators, physicians and staff should work together to stay abreast of coding education, effective workflows utilizing technology, and building an effective team to assure goals are met ahead of critical changes.


Bookmark and Share


Post a Comment

Please login to post a comment.
Powered by Bondware
News Publishing Software

The browser you are using is outdated!

You may not be getting all you can out of your browsing experience
and may be open to security risks!

Consider upgrading to the latest version of your browser or choose on below: