Fundamentals of Coding that In-Office Training Doesn’t Teach
DOCUMENTATION
Brandy Brimhall
Many chiropractic providers and/or their coding and billing staff gain most of their training for coding right in the office and without much outside professional training. While in-office training is essential for the practice, there are often unknowns or uncertainties that are unresolved when it comes to coding. This often results in assuming, guessing, using a code that you may have heard through the grapevine, or just using a familiar code for no other reason than the office is just comfortable with it and it seems “close enough.” This results in heightened vulnerability for providers in the form of audits, claims delays and denials, and other related scenarios.
Regardless of y our level of training or the specialty for which you are coding, there aie some basic starting points that are great for everyone to review periodically, even seasoned coders. Understand first that coding is part of the foundation of your practice and serves as your primary (and sometimes only) method of communication with other payers, other providers, attorneys, and even auditors.
The chiropractic error rate is one of the highest in the entire medical field, which certainly raises concern in regards to chiropractic systems for documentation, coding, and billing. While training for chiropractic coding has come a long way, there is still ground to be gained to better ensure appropriate coding systems in practices. With ICD-10 being newly implemented there is no better time to review the fundamentals of coding.
As with any profession, there aie fundamental need-to-know details to better ensure correct application of responsibilities. The following paragraphs will outline some of those fundamentals for coding.
Coding is part of your practice’s foundation:
When establishing the foundation while building a house, the proper steps and components must be used and the blueprint must be reviewed regularly. If not, the results ai e a weak foundation and unnecessary and costly mistakes, and it is more difficult to securely construct the rest of the structure on top of such a foundation. Building and maintaining a business works exactly the same way. Owners/providers must take appropriate steps to ensure a solid foundation on which to build and have steps in place that allow this to be continually maintained. If not, you will find that there aie “cracks or holes” in the practice’s foundation, and that errors or oversights have occurred that could have
^The chiropractic error rate is one of the highest in the entire medical field, which certainly raises concern in regards to chiropractic systems fordocumentation, coding, and billing. J J
easily been avoided. In ternis of coding and billing, “cracks or holes” can translate to many things, such as claims delays or denials, audits, records reviews, complaints to payers or state boards/ organizations, allegations of fraud and abuse, penalties, attorney fees, loss of income, loss of cash flow, refund requests, and others. While these scenarios can’t always be avoided, they can be largely prevented simply by having adequate training and systems in place, and by periodically assessing these systems to minimize risk.
Coding is another language:
The first basic rule of coding is to understand that there is no “under-the-radar” practice today. In fact, if you ai e actively in practice, be assured that you aie on the radar somewhere.
Chiropractic coding can become a very robotic-like task where codes aie often selected out of routine or habit, which can lead to errors and payer scrutiny. Note that these errors aie preventable by simply recognizing the importance of coding and understanding why we code.
Coding is another language. Like a novel translated from
‘* Coders are expected to know how to utilize current resources and be proactive in doing so—to follow guidelines in place in order to communicate correctly in the coding language. J Ï
English to Spanish, your patient documentation (history, exam, subjective, objective, and other treatment information) is translated from the documentation format into code. For a novel, the greater detail provided by the author on the pages in the book allows readers to have a more clear picture and understanding of the story, characters, and events that unfold as they progress thr ough the novel. Patient documentation works exactly the same way. Greater detail provided in documentation will allow the “story” ofthat patient to unfold as he or she progresses through care from visit to visit. The clarity and detail in patient documentation allows this “story” to be translated clearly and correctly into the “language” of code. The coder’s responsibility is to translate clearly and precisely what is included in patient documentation into codes, such as the appropriate CPT, HCPCS, modifiers, and ICD-9/ICD-10. Inadequate documentation will result in incorrect coding. Lack of attention to detail and uncertainty in general coding mies also will result in incorrect coding. The bottom line is that coding and documentation must tell the same story.
To be fluent in the language of coding, coders ai e expected to know how to utilize current resources and be proactive in doing
so—to follow guidelines in place in order to communicate correctly in the coding language.
So what does the code language communicate? For those who are new to coding or unfamiliar with it, here is a basic description:
• CPT/HCPCS: Identify procedures and supplies that were provided to the patient. These codes say “what” was done with the patient.
• Modifiers: Further describe detail to support the CPT/ HCPCS. These codes offer more information and insight regarding the services and supplies provided. Modifiers work much like adjectives in a sentence and offer even more clarity to the treatment provided.
• ICD-9/ICD-10: Describe “why” the patient is being seen. Diagnosis codes identify conditions and symptoms that prompt and support patient care. This is why services and supplies provided to the patient must be adequately supported by diagnosis. This helps to validate medical necessity.
Coding is for more than just being paid by insurances:
The most common response by practices when asked why we code is, “To get paid.” However, there is a more broad explanation for the purpose of coding, which is useful to understand. As described previously, coding is the primary form of communication. Coding is also a global language in which providers of all specialties, as well as of other speakinglanguages, can determine what (CPT/HCPCS, modifiers) was done to help a patient and why (ICD-9/ICD-10) the patient was seeking care. This serves as a manner of patient safety as
well since it is common for a patient to be seen by many different provider types. Codes become a permanent component to patient records too.
For all of the reasons described previously, as well as for communicating with payers and seeking reimbursement, it should become even more evident that correct coding systems aie a vital component of every practice.
Additional tips for improved coding:
Remember that when you ai e coding, you ai e translating from one “language” to another. Many errors in coding aie the result of and can easily be minimized or avoided by simply having greater understanding of the coding process and general rules. The following bullets identify common conflicts that result in incorrect coding:
• Incomplete documentation
• Assumption or hearsay
• Routine coding practices
• Neglect of necessary training and review of coding rules and systems
• Use of aged information
• Use of condensed or altered code definitions
Coding manuals specify how to properly reference code descriptions. Coders and providers must be proactive in reading instructions and notes in code categories so that they avoid unnecessary errors. Having current coding resources and using the coding indexes properly cannot be emphasized enough.
Avoid “gray area” coding. In other words, don’t assume, guess, or take random advice without searching or asking for supporting evidence. If a particular code was used by another provider or providers and it seemed to worked for them, it still does not mean it is correct or will work for you. Coding is not designed to be “close enough” and the risk is not worth taking.
Don’t follow the old saying “throw it all out there and see what sticks.” Practicing by this standard will guarantee that eventually you will be defending yourself from potential fraud and abuse allegations; experiencing payment recoupment or suspensions; losing patient time in gathering information and records to defend yourself; and possibly paying an attorney, along with enduring a wide variety of other penalties. Not only is this just plain bad advice, but it also is irresponsible and dangerous.
Look at payer guidelines and local guidelines. It usually only takes a few minutes to check online and find guidelines for individual payers for your state, Medicare, workers’ compensation, and others. Providers can save themselves time and money by learning and implementing specific payer guidelines. Specific services are addressed as well as general guidelines expected for claims submission. This includes use of codes, modifiers, and other necessary information to avoid claims processing errors. State organizations also work to improve provider awareness of coding, billing, service-related rules, and other rules that aie necessary to build and work on a solid foundation in practice.
Seek help. Even coding experts look to one another and to organizations for clarity and information. Providers must do the same. Establish relationships with reliable resources and always ask for references for your reflection and your records. Payers, state organizations, and other established entities aie excellent contacts for providers and should be utilized for support.
Be proactive. When in doubt, take the time to confirm information and avoid making guesses or assumptions. Practices should take steps to avoid error and also to find and fix mistakes before payers do.
In closing, recognize that appropriate coding training and systems do provide a significant level of risk management for practices. Just like any solid business, periodic réévaluation of systems to ensure accuracy and compliance must be conducted within your practice and the coding systems in place.
References:
1. http://www.ama-assn.org/ama/pub/physician-resources/solutionsmanaging-your-practice/coding-billing-insurance/cpt/about-cpt.page?
2. http://www.healthlawyers.org/hlresources/Health%20Law%20 Wiki/Current%20Procedural%20Technology%20Codes%20 %28CPT%29.aspx.
Brandy Brimhall, CPC, CMCO, CCCPC, CPCO, CPMA ChiroCode Institute Director of Education www. chirocode. com 602-944-9877
