Although some medical practices have employed and utilized certified coders for decades, holdouts exist in our industry. Even the most seasoned managers and practice administrators occasionally need reminding of the importance credentialed coders offer to their organizations. This article points to the roles our coders can hold or grow into; it cannot possibly address all possible scenarios. As a result, practice managers should allow the mix of imagination and personal aptitude and attributes frame how individual coders are recognized and employed within each office.
According to AAPC's 2009 Salary Survey 56% of coders work in medical practices.* Of those, only a percentage are actually coding. The remainder work in any variety of job titles, a few in executive positions. Some educate, some bill, some follow-up and others lead the group. In practices where trade coders are not at the helm, it is vital to recall the value each certified professional brings to his or her workplace. For instance, without them, who would be responsible for updating superbills when codesets change and who could negotiate a bundling issue with payers?
A few years ago I wrote an article in a different professional journal outlining to coders how to dodge professional pigeon-holing. What is shared herein is meant to encourage leadership to ensure gates and pathways are open to coders willing and capable of contributing in greater capacity within the practice.
New possibilities out of current expertise
Practices anticipating or actively seeking electronic solutions should utilize master coders to assist with the transition. From the beginning, certified staff members should serve as subject matter experts for encoder or practice management software upgrades or purchases. As end users of these products, coders have intimate understanding the actual rules, guidelines, tools, functionalities and user preferences that are beneficial to coding, billing and maintaining compliance in those areas. With early buy-in from coding staff, those same individuals can act as change managers for the project and perhaps take the lead, train peers or project manage some areas.
If vendors have already been selected, coders play a vital role in the product's success within the practice. If EHR (electronic health record) installation has occurred, the package likely included an option for the patient accounting system, or interoperability to such a system. With the current trend in major health care drivers moving to electronic platforms, practices can benefit by automating superbills. In this instance, coders can lead the process of moving existing paper charge slips to accessible, standardized, electronic encounter forms. This not only exploits the available EHR technology, but supports coder growth by having continued maintenance and updating of the electronic forms, eventually employing the staff member to edit or augment the system. Coders can also serve as training staff for the electronic transition and assist clinicians in understanding the benefits, effectively navigating the encounter form and ensuring the accuracy of that data. Expertise in coding also supports the use of a certified individual in working with software vendor programmers in set-up of electronic encounter forms. By knowing that any evaluation and management (E/M) service conducted the same day as a significantly and separately identifiable procedure mandates use of the Modifier-25, a "rule" can be established within the encounter form that mandates providers to select that modifier when those conditions are met. Such an initiative not only hastens the revenue cycle processes, but ensures consistent review of each case against established criteria and minimizes rejections and denials on the back end.
Although my example above is a very simplified version of what is possible within the confines of existing technology, far more sophisticated possibilities exist based on the use of certified coders in any billing or coding system upgrade.
Within this move toward greater reliance on electronic data, whether numerical or narrative, there exists a basic reluctance to accept change. Regardless, coders must know that their roles shall change, but never fully go away. Since providers mostly complete their health record documentation inside a silo, having reviews by professional coders helps to maintain compliance, identify quality and growth opportunities on that front and increase appropriate charge capture and optimization of reimbursement. One method of achieving those goals in an increasingly more electronic medical practice is training coders to be clinical documentation improvement specialists.
The concept is hardly new, in that hospitals have begun utilizing health information management (HIM) professionals in such roles as electronic health record implementation has blossomed. Physician practices are no different. Especially for larger practices, the use of certified coders in scrutinizing records for medical necessity documentation, clarity, overall record quality and moving toward remediation with providers who need assistance pays off in either decreased risk or increased revenue-perhaps both. Documentation improvement specialists work in tandem with auditors, clinicians, revenue managers and denials management to prevent, circumvent or improve documentation quality in support of both quality health care and optimal reimbursement.
Certified coders fit into this role especially well because of their understanding of documentation requirements, payer standards, clinical knowledge and skill in utilizing the coding systems, guidelines and how this then plays into revenue functions. Although the specific functions of a documentation improvement specialist are substantially different than those working in the hospital setting, the basic skill set remains the same: attention to detail, ability to communicate effectively, expert-level work in the reimbursement systems and comprehending the continuum of care within a specific practice. Only the most seasoned, educated and well-rounded coders should be considered for this role, but by requiring certification, practices can be assured of attracting the proper candidate(s).
Relating to payers through coding staff
On the insurance side of industry, coders perform medical review, provider relations and claims processing. Although provider organizations should model structure on this basis, many have failed to follow suit. Payers recognize the value coding professionals bring to payment fee schedules, contracting, investigating suspected fraud, abuse and improper payments, as well as service utilization.
Practices can tap coders to analyze fee schedules to ensure they are competitive, reflect local market shifts and are easily tied back to expense. Fee schedule analysts ensure fair compensation to practices and allow the established schedule to reflect changes in cost for services, based on utilization and similar variables that can impact service cost.
In particular, certified coders bring vital experience to contract negotiation and establishment. Medical practices commonly employ medical doctors and practice managers in developing payer contract relationship. Unfortunately, coders may not be included in such committees. Because they understand the implications of specific clauses of any established contracts, coders can bring substantial protection to the physician practice. Additionally, health care providers contract with hospital groups, other physicians, laboratory services, Veterans Affairs medical centers and a host of other payer sources. In each of these contracts specific payment policies, guidelines and requirements are presented. Clinicians are usually not ideally poised to identify the full implications of such obligations and practice managers do not generally control the final, coded claim product. However, coders do have this level of influence, scope and an ability to train or educate peers; thus, they should review and make recommendations before any contractual agreements are signed and go into effect. The ramifications of not upholding these contracts have dire effects on practice revenue cycle and functions. Without coders, the practice is exposed and agreeable to whatever unique rules are established through the agreement.
Lastly, most of these contracts have some element of auditing, reviewing or monitoring implicit to the agreement to accept patients or payment from the other party. Coders, again, know the industry standards and are positioned to suggest changes or share audit standards with other staff, who can then ensure their practices and processes are in alignment with the agreement.
Many larger health care facilities have uncovered that without proper inclusion of coding experts on their panels, contracts, payment disputes and external monitoring do not fair well for the bottom line.
In larger organizations utilization review (UR) and quality management areas benefit from coder involvement. High functioning coders easily become data managers. This is especially helpful for quality managers who are seeking methods of easily identifying patient cases that meet selection criteria. Because coders classify all of those patient cases, the data need not be re-abstracted, just the specific and precise criteria established and a case mix produced from whatever data sources store this level of patient information.
Increasing payer scrutiny at controlling cost makes certified coders a good fit into any utilization review process. Although most payers will utilize registered nurses or similar clinicians, coders are superior by having grasp of the payment systems and properly classifying cases based on sound and authoritative advice from coding sources. While RNs may be trained in coding systems, most lack the credentials to support claims they can operate in such a capacity. When preauthorizing or selecting appropriate levels of care, coders can easily (and at a typically lower salary cost to the organization) garner the clinical information from patient records, relay that to payer UR staff and make recommendations to clinical staff regarding covered benefits, coverage criteria and similar determinations that impact the likelihood of practice reimbursement.
Payers have provider relations professionals to serve their contracted providers. In the physician practice, few, if any coders act as payer relations specialists. Although practice billers are more likely to know specific, recurring issues with revenue cycle activities and specific payers, coder are more apt to speak expertly on those issues. A credentialed coder should be able to articulate coding guidelines from authoritative sources and seek reconciliation through the contracted payer channels. Unfortunately, this is a relatively unusual role within the practice administration, though easily paired with the contracting role mentioned earlier.
Promoting from within
Giving your certified coders opportunities to function throughout the continuum of service in your organization keeps the best and brightest within the practice. Although some settings other than physician-based practice see greater coder turnover, it acknowledges our importance in this industry to be considered and promoted to roles like compliance officer, billing manager, front office staff trainer and the positions herein listed. Certainly other disciplines contribute to the overall success of each practice, but coders have a substantial spot in the fiscal health of your organization and continued viability of its revenue cycle. Growing them out of production coding roles only helps to support those same goals and promote a more compliant, accountable and regulation-savvy organization.
*http://news.aapc.com/index/php/2009/10/2009-salary-survey-results/
Kevin Shields, RHIT, CCS, CPC, CCS-P, CPC-H, CPC-P acts as the Academic Program Coordinator for the Healthcare Coding & Reimbursement program at Jefferson Community & Technical College in Louisville, KY. He holds a decade of experience in HIM. Kevin has published articles in the AAPC Coding Edge, Advance for Health Information Professionals, and BC Advantage. Kevin coordinates the River Valley Health Information Management Association (RVHIMA) Coding Roundtable, participates in the Ingenix Coding & Referential Advisor Board and is one of the nation's most active AHIMA Action Community for e-HIM Excellence (ACE) members. He is a graduate of the HIT program at Weber State University and has work experience in payer, provider, consulting, home health and hospital settings. Mr. Shields has previously led regional coding quality review audit teams, worked extensively with contracting and program integrity support, as well as coding compliance and HIM management. He may be reached at kevin.shields@kctcs.edu.
