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  coding strategy

Doing it Right the First Time

Maybe it’s time for a reset of our thought process.

JOHN RUMPAKIS, O.D., M.B.A.

As the age old question goes, why are we always willing to take the time to do something over instead of taking the time to do things right the first time?

This thought crosses my mind quite frequently as I answer e-mails, phone calls, insurance carrier inquiries and attorney information requests about medical coding and medical record compliance issues.

“Billing and coding”

If it were up to me, I would abolish the phrase “billing and coding” from our professional lexicon. The widespread misperception that “billing and coding” is just for revenue generation is inaccurate and outdated. Medical coding should NOT be used to inappropriately enhance your income.

Each U.S. physician is bound by HIPAA to follow two standards for providing professional services to a patient. These are described in the AMA’s CPT Codes and in the World Health Organization’s ICD-(9/10)-CM codes. CPT codes are used to accurately describe the very specific, delineated services provided during a patient encounter. A five-character code describes the complexity, severity, location, procedure, structure(s) evaluated, associated rules and guidelines implied by using that code that a physician attests to under the penalty of perjury with their signature. If a physician miscodes or mischaracterizes that encounter/procedure in any way, they are subject to both civil and criminal actions, as well as additional actions taken by the insurance companies themselves.

One code does not fit all

“John, I have a glaucoma patient, how should I code them?” My answer is “I have no idea.” I could gather five patients with the diagnosis of 365.11 (Primary Open Angle Glaucoma), and each could have a different office visit associated with that particular encounter. Coding an encounter is never based upon the diagnosis, but on the individual patient presentation and individual care that you performed and recorded.

Each patient has different presenting reasons, personal and family histories, clinical findings and risk factors and requires a different (individual) level of assessment and care ­— thus, a unique individual code.

Follow the rules

We, as physicians, have to follow the rules of the CPT, the ICD and HCPCS as well as the rules of our contracted carriers that we agree to in our provider agreements. The burden of knowing those rules is ultimately borne by the physician, as it is their NPI number on the claim form and their signature in the medical record.

To illustrate this, let’s take something we use every day: the CMS 1500 form. Have you read the faint red print on the back? Everything you are attesting to by your signature on the front is spelled out here. Remember, ignorance is not a good defense.

A final thought

The profitability of providing medical eye care services in your practice is nothing more than a by-product of providing the clinical standard of care to the highest level that your license allows, accurately recording the clinical care in the medical record, then translating the medical record into five-digit codes that can be processed for payment (irrespective of who the payer is).

That is why “billing and coding” is such a misnomer. Medical coding means completing your medical record properly, and taking the time to learn how to do it right the first time, can result in not only having a profitable practice, but one that is essentially bulletproof. OM

DR. RUMPAKIS IS FOUNDER, PRESIDENT AND CEO OF PRACTICE RESOURCE MANAGEMENT, INC., A CONSULTING, APPRAISAL AND MANAGEMENT FIRM FOR HEALTHCARE PROFESSIONALS. E-MAIL HIM AT JOHN@PRMI.COM, OR SEND COMMENTS TO OPTOMETRICMANAGEMENT@GMAIL.COM.