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    Betsy Nicoletti, MS, CPC, founder of CodingIntel, almost does not need an introduction on account of her extensive work to simplify coding for physician practices as a coding expert, speaker, writer and consultant in the healthcare space since the mid-1980s.

    As she explained on a recent MGMA Insights podcast, that career began as a medical assistant and evolved to running a network of physician offices at a rural hospital in Vermont. “My boss was the administrator, and he would hire physicians,” Nicoletti said. “[The doctors] would stay for a short while and they would leave.”

    The primary care doctors were looking for guaranteed compensation and sought to be employed, and it was in the best interest of the community to keep them there, Nicoletti said. With time, the group would add OB/GYN, general surgery and other specialties to the group before eventually becoming a federally qualified health center (FQHC) after Nicoletti decided to try her hand at being a practice management consultant.

    “I had a community health center that I worked with a few days a week, a neurology practice that I was the practice manager for,” Nicoletti said. “But here’s the truth — I’m terrible at operations, so I branched out into coding.”

    Q. What was the biggest challenge in moving through those roles?
    A. As I was starting consulting, one of my colleagues said, “doing the work is easy, but finding the work is hard.” I’ve never found it easy to sell, and that remains the challenge today.
    Q. What specifically led you to coding?
    A. A colleague said, “you should do coding, there’s so much need for that.” … There were a couple of things that drew me to it. I love working with primary care, and they need help with coding. I felt like I had a good balance about coding. Back in the day, you would see consultants who would say, “hire us, and we’ll increase your revenue by 40%.” Then there are those coding consultants who say, “be careful, you’re going to get audited,” and put the fear of the OIG in you. I feel like there should be a balance there.

    Our goal as coders is not to get you the most money possible. Our goal is to get you as much money as you’re entitled to, and that you’re going to be able to keep. My goal isn’t to terrify you into thinking that there’s an auditor behind every bush, but you have to have enough care about your coding — paying attention to compliance, looking at the new rules — that you don’t inadvertently get yourself into terrible trouble.
    Q. What is it about working with practices on coding that you love so much?
    A. I think you make a difference on both sides of that balance. [Let’s say] you have a physician who is super conservative, they’re never going to bill a high level — they don’t want to get audited and they’re depriving their practice of resources that they should have. I love working with those groups, where, legitimately and honestly, I can find revenue for them. I also feel like it’s important, if you do run into a group where what they’re doing isn’t right, that you give them that feedback so that they have the chance to make it right for themselves.
    Q. How does someone go about simplifying coding for physicians?
    A. I don’t want to brag, but I do feel like it is one of my skills to take something complex and bring it to the key points that you need to know. Twenty years ago, I could more honestly say I was simplifying, but CPT codes have grown. I did a little survey to my email group and asked, “What’s your oldest CPT book? And how many pages is it?” In 1985, somebody had a CPT book in their office that was 450 pages long. This year, it’s 1,200 or 1,300 pages long. How can we expect our clinicians to cope with that kind of enormous growth and change in coding, not to mention payer rules? The CPT book isn’t even in numerical order anymore, so it’s really hard to use.

    If I meet with a group of physicians, I always ask them first, “before I start, what do you want to make sure we get answered today? What should we talk about?” Because I want to engage them and have it not be adversarial, because sometimes it can be adversarial. I try to keep the words “must” and “should” out of my presentations.
    Q. Can you give an example of what that simplification looks like in practice?
    A. The best thing to do is start with education with the physicians, NPs and PAs, as well as the coders and the staff. Then I like to review notes, just a small sampling, and then meeting individually with a physician, NP or PA, or with a small group. And then on-site coding support is critical. They’ve got to be getting somebody there who’s going to be their go-to person to look something up for them, help them be able to audit some records. Then a program, because there’s always turnover in every specialty. In primary care, there’s a lot of turnover.
    Q. With those educational pieces in place, what are the KPIs that a practice would want to track to analyze performance?
    A. Depending on the specialty, we want to look at the percentage of E/M services that they’re billing in each category, new and established visits, or (if they’re hospital-based) the hospital services. If we can find out the percentage of modifiers that they use and what the norm is for their specialty. That varies markedly; there are some specialties where they have 70% use of Modifier 25. Maybe I’m exaggerating slightly — that’s confounded by payers that require Modifier 25 when they shouldn’t.

    We always want to be looking at outliers. If you’re looking at your E/M distribution or your use of Modifier 57 or Modifier 24, you want to compare your providers in the same specialty against themselves and national data.

    I worked with this very small practice in Vermont that remained private through the years. They told me that they look at one metric every month: the percentage of established patient visits billed as Level 4 visits. There weren’t that many new patients; the practice was essentially closed. They just wanted to look at how many Level 4 visits. If it was 20%, that was way below the norm; if it was 80%, they might want to look and make sure that notes were OK.
    Q. How have you seen the staffing challenges in healthcare impact coding and billing the past two years?
    A. More coders are working remotely and not having to come into the practice. It is hard to find coders; trying to find an experienced coder is difficult. Telehealth has made it worse because the rules for each payer are different. My clients built these enormous grids for each payer, as a TPA, as a Medicare Advantage plan — what place of service to use, which modifier, do you need to document time? Essentially, my groups have every single telehealth note being reviewed, whereas before with a typical office visit in many practices, the provider finishes, they close the note, it goes through an edit, but it basically goes out without being reviewed — not anymore, not for telehealth. That’s been a real problem.
    Q. Do you have a favorite code?
    A. I like the E/M code set. I liked it a lot more when the set was numerical. I’ve come to like reading the Medicare Final Rule — it’s like a puzzle sometimes, seeing what their policy is, what they’re thinking. I feel like that is my specialty.
    Q. What do practices often get wrong about coding in building their strategies or processes? Where are they creating inefficiencies?
    A. I think doing double work is a problem. Sometimes we have the provider code, and then a coder codes on top of it. Then we have to decide where the truth lies. In general, we want a clear distinction about what is the role of physicians, NPs and PAs: Do they get to select their codes or not? If they don’t, then don’t have them do it — let’s not do double work.

    I do think that it’s important when you’re hiring a coder to find somebody with a balance who’s going to be invested in the success of the program, but also isn’t too driven by fear.
    Q. The pandemic has put a lot of stress and strain on healthcare workers. What is your work-life balance? What’s the secret that brings you to being in good spirits?
    A. Where I live in Massachusetts, I’m an easy drive to several places where there are woods, where you can take your dog for a walk off leash. In the morning before I start working, I take a walk in the woods. It just helps.

    Additional resources:

    This episode is sponsored by:

    • HSG
    • MGMA Events - Click here to register for the Medical Practice Excellence: Financial Conference, March 31-April 2 in Atlanta. 

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    The MGMA Insights podcast is produced by Daniel Williams, Rob Ketcham and Decklan McGee. 


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