Too
little attention is paid to documentation, coding, and billing in many medical
practices. For patients, documentation simply means that your doctor is
providing an account of your visit in your medical record. However,
documentation and coding can affect revenue, quality of care, and possibly
expose clinicians to legal consequences.
Too
often doctors and other healthcare providers (PAs, NPs, etc.) cruise through
their documentation and coding training, giving short shrift to the nuances of
this key aspect of care delivery. In fact, many medical practices offer no
formal training in the use of Current Procedural Terminology (CPT©) codes and
Internal Classification of Diseases (ICD) codes. In these instances, despite
such inadequate preparation, doctors simply begin seeing patients and
documenting medical visits in the electronic health record (EHR). I’m sure that
most clinicians would rather just see patients than bother with the billing
component of care delivery, which includes charting the patient’s condition,
selecting the correct CPT© code of the 10,294 that are available, and choosing
the right diagnosis codes out of the 68,000 that are available. The
difficulties involved are further complicated by the hierarchical condition
category (HCC), which involves assigning risk scores to patients. Add to these
complexities the effects that coding may have on compensation, and you can see
that the process is rife with potential problems. For instance, many
physicians, especially those working in health systems, are paid for their
delivery of care on the basis of a work relative value unit (wRVU), a measure
determined by Medicare.
Accurate
documentation helps provide a baseline of the cost of patient care, and it can
affect profitability. It’s essential that clinicians accurately document all of
their work so that they not only provide a complete medical record of delivery
of care but also receive full and fair reimbursement for their services.
Accurate coding can also offer some protection during audits. On the other
hand, inaccurate coding can have unintended and deleterious consequences.
What Is Coding?
Coding
involves charting and documenting the service provided during a patient’s
visit. When you enter your doctor’s office, he or she may provide the services
required for a low-intensity office visit and may document having provided Level
2 service. The problem arises when the doctor, whether intentionally or
unintentionally, provides Level 2 service but documents that a Level 4 service
was provided, or documents that Level 2 service was provided but bills for
Level 4 service. Such disparities leave doctors open to charges of having
overbilled for a visit, overbilling that risks fines and, in the worst cases,
jail time.
wRVUs and Compensation
Medicare
assesses medical work on the basis of wRVUs. Figure 1 below shows wRVUs for
five codes used to document new patient visits in 2019. After your first visit
to a new doctor, the doctor may have billed your insurance company using one of
these codes. These five codes range in meaning from least comprehensive medical
service (99201 or Level 1) to most comprehensive medical service (99205 or
Level 5). In theory, more work is required for a Level 5 visit than for a Level
1 visit. Medicare pays doctors for the level of service provided. So if a 99201
service was provided, a doctor is paid less than if a 99203 service was
provided. If a 99201 service was provided but a 99203 service was documented
and submitted, the doctor has overbilled.
Good
documentation is critical not only for the sake of protecting doctors and other
medical practitioners from the legal risk that attends incorrect coding and
overbilling but also for the sake of providing accurate documentation of care
and good quality of care.
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