Physicians are subjected to more demands from mandated programs and increased coding complexities, including directive models such as the Merit-based Incentive Payment System (MIPS), Patient Centered Medical Home (PCMH), Hierarchical Condition Category (HCC), Diagnostic Cost Group (DxCG), as well as many quality programs, incentives and reporting requirements. There are also ever-changing industry regulations, insurance claim edits and carrier payment policy updates.
As a result, there is greater emphasis on detailed medical record documentation; health status related coding and quality measures, including complex requirements for Transitional Care Management (TCM) and prolonged services; the expanded diagnosis (Dx) requirements of Risk Adjustment Factor (RAF) coding; Local Coverage Determinations (LCDs) and National Coverage Determinations (NCDs).
ICD-10 has increased the need for Dx coding to be captured at the highest level of specificity, and subsequently has a direct impact on risk contract revenue. Thus, medical coders are responsible for delivering on most of the burdensome regulatory rules that physicians may see as a distraction to patient care.
At one practice, a twice-annual audit meeting between the coding department and providers, driven solely by coding priorities and concerns, had to be reevaluated. The auditing focus helped create a grading mentality that made the physicians and the coding support staff uncomfortable, resulting in divisive interactions. After reaching out to colleagues with similar practice models and goals, senior practice management confirmed that these issues were widespread. Most practices did not hold regular coding meetings and simply sent out information for physicians to independently review and interpret. Other practices reported a mix of semiannual and annual group or individual coding meetings with a narrow focus on documentation review and office visit level auditing.
The consensus from the other practices was that those approaches did not work. The practice had to restructure future meetings to address these issues and to foster a collaborative and supportive environment. A resolution had to be established prior to the next round of scheduled meetings.
Evaluation and planning
An ad hoc committee was created to work toward resolving the fundamental issues with the coding meetings. The team consisted of the group’s physician chairperson, chief operating officer (COO), director of patient accounts, coding manager and a few key physicians.
The team confidentially met with physicians and coders separately to develop a comprehensive understanding of their concerns and frustrations. These meetings demonstrated the committee’s commitment and resolve to make improvements. It was essential to listen to the feedback in an impartial manner and to empathize with physicians and coders. The committee then met to review and discuss the feedback and to consider the best resolutions.
Physicians reported feeling as if they were being confronted with a list of demands that had no connection to patient care. They hoped coding staff could offer support and understand their focus on clinical care while providing information in a helpful and useful manner. The coding staff reported feeling uncomfortable in an auditing role with physicians and wanted to be recognized as a valuable resource. They also thought that physicians were not responsive to coding-related matters.
The committee determined that the practice needed to completely revise the outreach efforts and structure of existing meetings or discontinue meeting with physicians on a one-on-one basis. The following two options were considered:
- Discontinue one-on-one meetings with physicians and communicate with the group through general announcements and notices, which could reduce immediate tensions and save time yet not establish a stronger working relationship between coders and physicians.
- Restructure the meetings and change the focus to one of physician support, which would demonstrate the coding department’s commitment to practice-wide initiatives but cause some unpleasantness in dealing with challenges head-on.
After open discussion and input from the committee, it was decided to restructure the meetings. The committee then began the restructuring work to transition from an auditing meeting format to one of provider support.
Plan implementation
A physician leader was appointed by the committee to help promote restructuring efforts and focus on sensitive clinical coding topics and challenges at a physician’s clinical level. This leader helped physician peers recognize the validity of the work and cultivated a positive collaboration between physicians and coders.
The meeting’s name, format and tone were updated to set a positive expectation for the future. “Coding audit” soon became “coding support.” To respect limited schedules, meetings were proposed around physician schedules, and lunchtime was identified as the preferred meeting time. To further add a positive tone, coders provided lunch. Meetings outreach was tailored to physician preference, as some preferred EHR task requests rather than nonclinical email.
A collaborative approach
The practice needed to broaden the meeting’s focus beyond traditional office visit leveling to create more personalized and targeted discussions based on individual provider needs, while communicating shared practice updates. Coders were expected to reach out to providers prior to meeting to determine what general coding updates and provider-specific objectives should be reviewed.
Anticipating physician needs
Coders should come prepared to the meetings with concise, fully researched and useful information. Handouts are helpful if information is organized and relevant. When preparing and reviewing discussion topics, coders should look for missed opportunities as well as deficiencies to create a balanced mix. If a physician’s E/M visit leveling needs to be reviewed, it should be as important to look for incidents of downcoding as it is for upcoding.
Supporting benchmarking data should also be used during discussions. It’s a useful tool to compare the practice and individual physicians to others in the same specialty to help identify outliers. This data is helpful in gauging physician-specific code usage patterns for comparison. This could be as simple as compiling a monthly report of the total volume for each visit level by provider for comparison nationally and internally. However, a physician’s specific data is confidential and should not be shared with fellow providers, which could cause unintended discord and break the implied privacy of the personal coding support meetings.
An initial review of each provider’s E/M visits should be done prior to coding support meetings, even if benchmarking shows that a physician is in line with the norm for a code or level. For instance, a physician could be on par with the average percentage use of a code, but upon closer investigation he or she is routinely downcoding complex chronic patients.
During support meetings, coders should provide, and refer to, supporting reference materials, documents or articles. Reference books for CPT, HCPCS, ICD-10 and others should be brought to each meeting even if they aren’t used — the books serve as a reminder that coding staff are delivering information from other entities and are not creating the directives.
When a guideline for the proper use of a code is discussed, the name of the entity involved should always be referenced. This reinforces that these directives are dictated by outside organizations beyond the practice’s influence. This should encourage physicians and coders to find comradery in shared frustrations and place blame appropriately, not with the coding department.
When coding staff communicates with physicians, inflexible statements should be avoided, such as “You cannot use that Dx,” or “That is not the right way to level a 99215 visit.” Instead, factual statements such as “The Centers for Medicare and Medicaid Services (CMS) requires the use of this screening Dx code in this situation,” or, “CPT guidelines define 99215 under the following criteria.” This places coders in the position of providing information, not commanding an action from a physician.
“Help me understand…,” is a useful starter phrase that coders can use to talk through a conclusion a provider has come to as a result of his or her advanced clinical knowledge. A coder may not see diagnosis connections or comorbidities from the documentation as it exists. This conversation starter usually leads to an understanding that each note needs to stand on its own. Documentation needs to be understood, without unexplained clinical conclusions or thought processes applied.
EHR system templates should be expanded and fully utilized, as they have historically been well received when physicians are involved in their development. They should serve as a reminder of what needs to be documented for a particular service; for example, prompts can remind physicians to note severity, local, initial, subsequent or sequela encounters.
Coders should be mindful of the EHR system views that physicians see and their use of terminology. Coding support staff should not speak primarily in codes unless a physician is accustomed to the reference or assume that one physician accesses system information the same way another provider does. Coders should ask providers to bring their laptops to meetings so workflows can be accessed by physicians in their preferred way. If an EHR system problem is mentioned by multiple providers, it should be brought to the attention of the applications department. Any solutions or workarounds should then be shared with other physicians who experience similar problems.
The coding manager should work to pair physicians with coders who have a compatible communication style. If the experience is positive for both parties, this should help encourage an ongoing collaborative relationship.
Support meetings
The committee decided support meetings between each physician and a coding department representative should be held twice a year. With the coding manager’s oversight, detailed summaries should be prepared outlining the subjects discussed, individual provider issues addressed, physician concerns and general findings. These summaries should be given to the physician chairperson, COO, director of patient accounts and the appointed physician coding leader for review. Meeting summaries prove useful in identifying problems of mutual concern among physicians and for assessing performance at both the physician and practice level. Practice-wide concerns should then be addressed by the appointed lead physician at regularly scheduled department meetings to reinforce the goals of the practice. This process should also prove helpful if a physician takes a stance against a coding directive, policy decision or practice-wide consensus.
For example, the team encountered some physicians in the practice who were reluctant to use the DxCG risk adjusting diagnosis code for morbid obesity due to the harsh description that displayed on patient clinical summaries. Instead, they preferred to enter the generic obesity description. However, the generic code was less specific and did not properly report the severity of the patient’s condition or associated health status. This brought to light the different focus physicians have beyond a chosen code. The lead physician addressed the concerns at a department meeting, and physicians decided that the alternative EHR system description of severe obesity would be acceptable, as it linked to the proper risk adjusting morbid obesity ICD-10 Dx code.
This was a reminder of a coder’s role to explain why certain coding would apply and the benefits of its use. If a physician disagrees, the coder should acknowledge his or her position respectfully and leave it up to the lead coding physician to work out a solution within the department. If a resolution cannot be attained, then the lead physician should refer the matter to the physician chairperson and COO. This will help to preserve a supportive relationship and will put the responsibility of addressing conflict in the proper hands.
Lastly, support staff should keep an open mind and listen to questions and concerns raised by physicians. Coding guidelines change over time as clarification and consensus is made in the coding, medical and insurance industries. If concerns are raised, the coding department should offer to conduct a review of current guideline interpretations or to revisit the way the practice handles workflow. Consistent coding guidelines can be achieved by incorporating clinical and coding input into master reference sheets, ensuring contradictory information is not provided, as it may weaken physician confidence.
These meeting changes may entail the coding department taking on additional duties, such as coordinating with other departments on workflow development or involvement in resolving EHR system challenges. The expanded role of support should lead to a deeper understanding of the challenges physicians and coders face and achieve a more collaborative, rewarding experience for all.
Positive change
Physician participation and cooperation in coding matters increased significantly. This led to improved documentation, higher resulting compliance, greater HCC risk Dx capture and increased revenue. Physicians better understand complex services such as TCM, which improves billing and reduces initial insurance denials for improper Dx linking, and reduces the use of unspecified coding.
The appointment of a lead physician and ally helped bridge the gap between clinical priorities and coding concerns. The collaborative relationships led to a smoother transition through ongoing coding-related changes and to a more positive work environment. Physicians praised the support efforts, and coders reported a higher level of job satisfaction and sense of appreciation.
Editor’s Note
This article was adapted from a paper submitted toward fulfillment of the requirements of Fellowship in the American College of Medical Practice Executives. Learn more about ACMPE certification: mgma.com/acmpe.
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