Medical coding is an extremely important part of any medical practice. Having the proper experience and know-how will lead to accurate reimbursements and a compliant office. However, without that knowledge medical coding can dam the cash flow and suffocate the financial situation of your practice. Here are 3 very common problems with medical coding.  

1. Clean Claims - Without a doubt things will happen and some of your claims will get submitted without having everything correct. This happens very frequently, and being able to submit a clean claim will help you get paid faster, more accurately and avoid any issues with compliance. 

In a recent article Crystal Miner discussed Claims Submission with our readers. The importance of having a defined process is critical to submitting a clean claim. I know you are thinking, "Obviously!" well, that is obvious, however, most people set a process in place and do not improve upon that process. If you are still getting a lot of claims denied, ask yourself a few questions. Why are they getting denied? Who is responsible for that part of the process? How can we remedy that and get cleaner claims submitted? Answering these questions and continuing to improve the process will no doubt allow you to overcome this common problem and achieve a higher rate of 1st pass submissions. 

It is no mystery that today’s healthcare comes with mountains of paperwork.  As a consumer we see the front and back slopes of these mountains, but rarely the summit.  This piece of the equation falls on the providers and their administrative staff.  Consider this:  Where do you think all of those confusing details about your diagnosis, care, follow up, and ultimately your bill come from?  Someone has to document everything about your care...start to finish.  Just a piece of this process requires the physician to document their care, which is used for the medical coding to assign diagnosis and procedure codes for insurance reimbursement.  This piece alone requires time and a high level of expertise.  A recently published study in the Annals of Internal Medicine found that for every hour physicians were seeing patients, they were spending nearly two additional hours on paperwork.  It is difficult for me to imagine a physician pursuing the medical field and truly recognizing this administrative burden before it is too late.  Many physicians are trained once in the field for these pieces (if at all), including the sophisticated medical coding process.  This barrier to care is enormous and it bleeds over into the patient experience.  Have you ever needed care and then sat with a physician while they type into their laptop?  They are documenting everything...what’s wrong and what they are going to do about it...and that is just a start. 

The study confirmed what many physicians have already observed (such as James Sanders, MD in this 2005 editorial for Family Practice Management): the amount of paperwork that doctors have to do is out of control. Led by Christine Sinsky, MD, at the American Medical Association, the study followed 57 U.S. physicians in family medicine, internal medicine, cardiology and orthopedics for a total of 430 hours. In addition, 21 physicians completed after-hours diaries. The results? Physicians spent 27% of their time in their offices seeing patients and 49.2% of their time doing paperwork, which includes using the electronic health record (EHR) system. Even when the doctors were in the examination room with patients, they were spending only 52.9% of the time talking to or examining the patients and 37.0% on paperwork.  The doctors who completed the after-hours diaries indicated that they were spending one to two hours each night doing...paperwork (or the EHR).  I have seen it.  I watched a friend last week sit at his son’s wrestling tournament with a laptop doing this work.

The United States uses a code set called ICD-10 to classify diagnoses when patients require medical care (International Classification of Diseases, Volume 10).  The system and process can be a nightmare for healthcare providers in their effort to provide and be reimbursed for quality patient care.  A code is selected that matches the cause of the illness or injury as closely as possible, so you can imagine how crazy some of these codes can be.  Consider the fact that inclusion in this list usually means multiple occurrences of these situations...enough to merit a specific code. 

That being said - here are a few highlights that we have been compiled over the last couple of years:

You hear a loud pop in your left arm, followed by intense pain. You visit the doctor and sure enough, it's broken. As the doctor examines you, he or she will most likely be sitting at a computer during your visit typing notes, or writing down on a clipboard documenting what has happened to your arm. Once the visit is over, the doctor needs to get paid by the insurance company. This is where medical coding comes in. The doctor cannot simply send over the notes from your encounter. The insurance company requires a medical code. A medical code in this situation would look something like this:

"S52.92XA"

There could be a handful of similar codes that help document the visit to your doctor. 

Therefore, medical coding is the translation of medical reports into a short code used within the healthcare industry. This helps summarize otherwise cumbersome medical reports into efficient, data-friendly codes. While complex and detail-driven, coding really comes down to knowing how to navigate the three main code sets: CPT, ICD, and HCPCS. These code sets help coders document the condition of a patient and describe the medical procedure performed on that patient in response to their condition.

The entire world depends on medical coding as defined by WHO (World Health Organization). We use it to better understand the overall health and wellness of people around the world. In the US we also use it to help providers get reimbursed for their services by medicare and other insurance companies. Where did it start, and how did it come to be? 

Infographic: Medical Coding History Timeline

Origins can be traced back to John Gaunt a physician from London who lived in the 1600's. He developed a system to document what was happening to his patients to better understand the mortality rate in England. The study became known as "The London Bills of Mortality". Initially the bills of mortality was to determine the reason children under 6 years old were dying.  

Medical coding can be full of unknown terminology and TLA's (three letter acronyms). It can be daunting and often times overwhelming to have a slew of words coming at you that might sound like Mandarin to an unfamiliar ear.  Our staff’s experience combined would probably equal centuries of medical coding knowledge, yet at times we will still hear a word that we are not familiar with.  We thought it would be useful for industry peers to create this resource full of medical coding vocabulary and key terms. Without further ado let’s get started: 

Clinical Modification

This designation, created by the National Center for Health Statistics, is added to the ICD code sets when they are implemented in the United States. The ICD-10 code set went from 14,000 codes to over 68,000+ codes with the transition to ICD-10-CM. The term "CM" added to the end stands for "clinical modification". 

The concept is quite simple: Determine what is wrong with the patient, and then document what you do about it. As simple as it may seem, providers all across America struggle with this highly impactful piece of the business. Revenue and regulatory compliance are two of the most discussed topics of impact.  While those two factors are of the upmost importance submitting clean claims remains one of the most important parts of any providers clinic. 

Where do you start whether you are a physician, administrator, or an integral part within the revenue cycle?  Below are three very important points to consider:

It seems like a simple concept:  Document what is wrong with the patient, and what you are doing about it.  Yet, despite clear and highly visible impacts to any healthcare organization, the war for improvement rages on in every provider office across the country.  The two hot spots most often acknowledged are impacts to revenue and regulatory compliance.  We will talk about the importance of those factors – but I would also submit that clean and actionable patient information is a critical piece of our nation’s healthcare strategy.  More on that in a bit.

Where do you start whether you are a physician, administrator, or cog in the revenue cycle machine?  Here are a few key strategy points to consider:

What does success in 2018 look like to you? Your probably not thinking about taking your single provider practice and expanding into 100 physicians. You probably aren't even thinking about doubling growth. Most people are looking for some steady improvement over 2017. Good news, that is extremely feasible with just 5 simple improvements. 

When exploring the option of outsourcing any or all of your revenue cycle processes there are many factors to consider.  There are at least a thousand ways to dissect this, and many positive outcomes and advantages.  There are certainly pitfalls to avoid, we will start with a few of the many misconceptions relating to hiring a revenue cycle management company.

Here are 7 misconceptions about outsourcing in healthcare:

Misconception #1: Your Reimbursement Will Drop if you Outsource