April 23, 2014
5 Minutes with
BC Advantage (BCA): Could you describe your experience as far as an
HCC Coding/Education Account Manager?
Gail Gordon (GG): My experience thus far as an HCC Coding/Education
Account Manager has led me to be a more effective coder. Coding for the HCC
model is diagnosis based, so it is vital that I understand disease processes
along with A&P. Part of what I do is to uncover suspected conditions that may
exist based upon the clinical documentation provided in the medical record.
I wouldn't be able to do this vital part of the job without an understanding
of disease processes and the typical treatment options available. Once a suspected
condition is discovered I collaborate with the clinician asking him or her to
review the chart and the discovery I made. Ultimately the decision to use the
information I provide is up to the clinician and the give and take discussion
we have is highly informative and educational which then leads me to be an even
BCA: What about this particular field interested you and why?
GG: I honestly came into the HCC coding world after years on the Revenue
Cycle Management side and had never done HCC coding before. I wanted to expand
my knowledge base and challenge myself. HCC coding has done that for me. I also
believe the way my clinicians approach medicine which is a very old school,
whole patient approach helps the patient be healthier and keeps their acute
care visits to a minimum. I have seen how successful a practice can be first
hand with this approach and how well taken care of the patient panel is based
on this approach. The HCC model which is Medicare Risk model is based on diagnosis
and is a statistical model. So payment is based on diagnosis and not CPT codes.
By reporting the correct diagnoses yearly and treating the patient fully the
cost for the patient Out of Pocket goes down and the patient's health profile
should be stable or improve based on his disease processes because the PCP is
aware of and is actively treating all the patient's chronic illnesses. I am
of the opinion that the FFS world we have now is going to slowly be phased out
and more of these Risk contracts will be phased in because medicine has learned
that preventive care and management of chronic conditions are key to keeping
the population healthy.
BCA: Could you give us some insight on a typical day for you?
GG: Typically my day is one of reading clinicians' charts, finding
suspect conditions, and revealing coding inaccuracies that may occur (diagnosis
wise). I create educational opportunities for our clinicians that include emails
going over what was discovered and then I offer hints/suggestions to help lead
the clinician to the correct coding, or in cases of suspected conditions may
lead to long discussions about disease processes and how to link X to Y. Often
since our clinicians are not coders by education they will not list the manifestation
code or forget to "code first" a parent diagnosis, so a lot of what I do is
educational and collaborative. I work remotely 80% of the time and 20% of the
time I do site visits so that I may be an onsite resource for the clinicians
I also help establish our clinicians into the HCC Model spending time on site educating coders on how to data mine a chart for suspected and active HCC diagnosis codes. I work with new and established clinicians to improve documentation to fully paint the medical picture of the patient.
BCA: As an ICD-10 educator and trainer, how easy/hard would you say
it's been to get your clinicians ready for this transition?
GG: We are currently working on an educational program for the clinicians
which will go live by June. The goal right now is to beef up documentation for
the ICD 9's we bill because once we do that then the transition to ICD 10 will
be a bit smoother. My main focus right now is to reassure my clinicians and
to demystify ICD 10. I am currently working with my clinicians to no longer
use the unspecified codes and to delve deeper into the disease to give me the
full picture. When reading charts when an unspecified code is found, the question
is asked is there a more appropriate code? And a discussion is started to bring
the clinician to suggested code with the rationale that ICD 10 expects a complete
BCA: Do you feel you current strategy and tactics will be effective
with the extended deadline for ICD-10?
GG: I am absolutely certain that this strategy will work for my clinicians
because I am already seeing progress. Again it becomes this process of staying
ahead of the transition, reassuring our clinicians, and gaining and maintaining
their trust, that I have their patients and their correct documentation as my
first priority. I am confident that our clinicians will be ready for October
1 from a documentation point of view.
BCA: Do your clinicians understand what ICD-10 means to their day-to-day
GG: I believe they have an idea that they will need to document to
a higher specificity and delve deeper into their patient's health profile but
honestly with HCC coding we already do that to a degree. I think because our
clinicians are Risk Advantage docs they are used to being diagnosis- driven
and that gives them a small edge in being prepared for ICD 10.
BCA: How do your training materials prepare you and your trainees to
perform effectively for the changes made with ICD-10?
GG: I did the AAPC 16 hour online course work and I believe it helped
me by giving me concrete examples of how to document for ICD 10.
BCA: When do you think everyone should start preparing themselves or
their office for these changes?
GG: With ICD 10 beginning in October, I think it's important for coders
and billers to be ready by April/May so that they can help their clinicians
prepare for the transition. I hesitate to encourage physicians to start preparing
before June, because my concern is if you don't use it you'll lose it, like
any foreign language. I think if clinicians stop using NOS codes now and start
coding and documenting towards greater specificity NOW, then ICD 10 will be
an easier transition. Coders and billers can encourage their clinicians to do
this by pointing out the more specific code when they see the unspecified codes
in use. That simple step will empower the clinicians to delve deeper and make
the transition smoother.
BCA: How did your degree prepare you for your career as an Education
GG: My Master's Degree in Health Care Administration/Education has
helped me in my career because it taught me team work, and how to create action
plans for educating clinicians. Having a degree and certification gave me credibility
with clinicians and the confidence to back up my findings and suggestions. I
would encourage every coder to obtain at least a BS in Health Care Administration
because it is important to understand the business of medicine and how documentation,
ICD 9 and CPT 4 affect the revenue cycle of any practice.
BCA: What has been the biggest hurdle for you so far in your career?
GG: The biggest hurdle for me so far has been the need to keep learning
and keep growing. I'm never satisfied with my current educational level and
always feel the need to branch out and learn more. The business of health care
is always adapting and moving forward, my hurdle is staying on the cutting edge
and making sure I offer our clinicians the most up to date information available
BCA: What has been your biggest achievement?
GG: My biggest achievement at the moment has been helping the practice
succeed in the HCC model. Teaching the clinicians how to document for a diagnosis/statistical
model was challenging but once we were all on the same page, and they knew I
was there to help them, this practice has seen an improvement in the scores
and revenue. I find that clinicians by nature love to learn, so I tapped into
that curiosity and penchant for detail in my approach, and I couldn't be more
proud of this practice.
BCA: Can you give any advice to our readers who are looking to obtain
the same career as you?
GG: I would encourage the readers to get at least a BS in Health Care
Administration. Spend time in a billing office and learn Revenue Cycle Management
and then get your CPC if you haven't already. The wealth of knowledge afforded
to you through understanding the business of medicine is immense and understanding
the Revenue Management side of medicine will only make you a better coder and