Date Posted: Friday,
January 01, 1999
Let's get uncomfortably honest. With continued reimbursement cuts, like this year's $9-12k per provider E/M cut, organizations cannot sustain 100% coding validation. Now, let's get brutally honest. This is compounded by a lack of truly skilled and knowledgeable coders looking to fill the open jobs.
It's time to find the best solution that solves both problems. The solution is simple, but it will require teamwork and strategy. Eliminate 100% Coding Validation as a process in your organization and develop the skills of your current coding team into an audit team. Eliminating coding validation does not eliminate the compliance or integrity of your documentation and coding, as this will occur through audit analysis. To get there, proficiency evaluations are required, along with education and training of the physician, non-physician-qualified providers, and the coding team to better equip them with the skills needed to audit the services.
Consider the following case scenario:
Barbara is a coder for a very busy cardiology practice with sub-specialties within cardiology and employs 12 providers. The cardiology practice is part of a mid-size health system that employs 145 providers. Barbara won the state lottery and has now decided to take her retirement from the organization and has given them a 30-day notice. The problem is that Barbara is the only member of the coding team who feels comfortable coding cardiology services. Jennifer, the coding manager, meets with Barbara to review her process to determine the best plan for the group's future.
Currently, Barbara is providing 100% coding validation on all services performed, including E/M services, office-based procedures, and surgical services. Barbara insists that ALL services must be reviewed as her providers depend on her. The monthly coding volume is high at approximately 600 E/M services and over 400 procedures. Upon retiring, Barbara will have been in her position for the past 14 years and is currently making $73,000 per year plus benefits.
As the organization is considering this scenario, elements that should be considered include:
- At the current claims volume, what is Barbara's current turnaround time?
- Timely filing is always a concern. While Medicare has a generous allowance, they are one of the few.
- If Barbara ONLY codes, and speaking generously actively codes 6 hours a day, a monthly volume of services would take her:
- 10-13 days for the E/M services
- 8-10 days for the procedure services
- In addition, this turnaround time is compromised by queries and timely documentation and signatures
- Additionally, Barbara will have days with meetings, vacation/PTO, and other duties related to her role
- Therefore, Barbara is reasonably at capacity with the current volume of coding
- This would then infer that to provide a quality candidate to replace Barbara to code these claims, the same salary range could be required
- Consider a feasibility analysis of what Barbara is doing for the organization
- Barbara's salary is $6,085 per month, making each working day valued at approximately $1,525
- The average E/M encounter reimburses $95 per encounter, and the clinic is producing, on average, 600 E/M services per month, which is an approximate weekly revenue of $14,250
- The finding of this analysis is that having all E/M services validated costs, on average, 10% of the E/M revenue
Compliance is worth a financial investment by the organization, but 10% of revenue is a high investment. Especially given that this does not include additional overhead expenses on the E/M service, such as billing, the physician, the support staff, the building, supplies, etc. The goal is not to entirely eliminate validation coding but to concentrate on high-risk areas for the practice, including:
- E/M services with modifier 24
- E/M services with modifier 25
- Complex surgical cases
- Surgeries that are out of the ordinary course with a 22-modifier
- Level 5 E/M encounters
Developing a plan for validation elimination begins with proficiency analysis and then segways to training and education before any coding validation is eliminated. Develop an internal plan for your organization, noting this is not an overnight process. If you need help, NAMAS is here to create your plan, help implement your plan, or consider coming to conference this year as we break down the process into actionable repeatable steps.
Your next steps:
Contact NAMAS for information about customized staff and provider training.
Read more blog posts to stay updated on the 2023 Revisions to the 2021 E&M Guidelines.
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