Legally, when a physician, physician assistant (PA) or nurse practitioner (NP) enroll in a Medicare, Medicaid or commercial insurance, the practitioner signs an agreement attesting that accurate claims will be submitted. Practitioners are responsible for claims submitted under their National Provider Identifier (NPI).
CMS’s E/M guide says,
When billing for a patient’s visit, choose codes that best characterize the services you give during the visit. A billing specialist or alternate source may review your documentation before you send the claim. Reviewer may help you choose codes that show the services you give to the patient. You must make sure:
- Your claim correctly shows your services
- The medical record documentation supports the level of service you report to a payer
- Don’t use the volume of documentation to decide the specific level of service to bill. 
The back of the CMS 1500 form specifically states that by signing the form the provider is attesting to the accuracy of the codes submitted. The fact that the claim is submitted electronically does not change that attestation. That is, whether the medical practitioner or a coder selects the code, the practitioner is responsible for the codes submitted on a claim form.
Not all practices do this the same way.
- In many private practices, the physician alone is responsible for selecting codes, based on the documentation, and this is done in the EMR, at the time the note is complete.
- In some academic practices or health care systems, and in groups that are employed by hospitals, all services are coded by a coder.
- And some groups do the work twice. The provider codes the service and then coder verifies the code or re-codes it. This can lead to adversarial interactions between providers and coders.
Coding physician services | Compliance
The stakes are high. Coding drives revenue. Coding compliantly is demanded of all practices. No practice wants to collect money that later needs to be returned to the payer. Physician compensation is often determined by the RVUs associated with the CPT® code that is submitted on the claim form. Health systems and hospitals want to ensure that services submitted under the group NPI are accurate and represent what was done and documented.
Who gets the last word when there are disagreements between what the physician coded and what the coder coded isn’t easily defined. There is no free lunch here. There will be issues to identify and problems to solve no matter which professional does the coding.
Finding codes for procedures can be difficult in an EMR. When providers do procedures, it can take more time to find the code than to do the procedure. (Well, maybe that overstates it). And, if it is a procedure that is done infrequently, the provider may select an incorrect code. The definitions in the EMR are not always complete code definitions, making it easy to select the wrong code. Some providers find a code and stick to it. All new patient visits billed as 99204s and all established patient visits billed as 99213s.
Clinicians are interested in taking care of patients, not coding, and can sometimes select less accurate codes because of it. And the search function in the electronic health record can return incorrect results, leading the provider to select the wrong code.
Coders can become too conservative, strangling revenue. Sometimes, coders are asked to code for specialty services that are out of their scope of knowledge, when a group hires a new physician. And, the cost of having someone read and code the notes for all encounters can be prohibitively high. Disagreements with providers can lead to adversarial relationships rather than collegial ones.
So, what’s a practice to do?
I am going to give you my opinion about responsibility for coding in practices. I know not all of you will agree with me:
Medical practitioners can code 80-95% of the services they perform. When they perform a service infrequently, flag the encounter and send it to the coder.
For the services they do day-in and day-out:
- provide coding education,
- audit periodically,
- help with how to search, and
- assign them the responsibility to select the code in the EMR.
- apply modifiers
- check for bundling
- check for services with coverage determinations
- review the documentation for services that are on their payer’s target list for audits or that have been identified in internal audits as having a high error rate
- code procedures that are performed infrequently.
One group I worked with set up an edit to stop claims billed with critical care and prolonged services, because an internal audit had identified those as having a high error rate. The coders reviewed documentation for those before submission. Have coders code procedures that are performed infrequently.
Internal Compliance Review
An internal compliance review will often identify either services that need review or providers who need education or who need to have all of their coding done for them. If the group is large enough, you can be sure there is one or more provider who codes all 99212s or all 99205s.
If coders are reviewing notes and changing the codes after the provider has coded them, there should be a mechanism to let administration and the medical director know how frequently this is happening, and in what direction the codes are being changed.
Most clinicians don’t want additional emails every time a code is changed by one level. Develop a threshold for alerting administration, the medical director and the provider about when to have a discussion and review. If 15% or 25% of codes are being changed by the coder, that requires a review and discussion. If the disagreements can’t be resolved internally, send a selection of notes to an outside firm for review.
Coding physician services | Keys to success
Everyone in the practice shares the same goals of providing excellent medical care for patients and collecting enough revenue to keep the practice’s doors open.
In many organizations, coding is centralized out of the practice location, reducing the interactions and opportunities for asking a quick question and getting feedback. If that’s the case, the coding department and practice management could set up regular meetings, even lunches to increase the interaction and improve the relationship between providers and coders.
And, if you are reading this and saying, “Wow, our practice doesn’t have these problems. We all work as a team,” I first congratulate you and second want to say some other readers envy you.
What can you do if there is already tension between the practitioners and the coding staff?
Providers want feedback about their coding. Set up regular meetings to give them feedback about their coding and documentation. A manager or medical director can attend if emotions are running high.
Give feedback when the record was coded at a higher level than documented, but be specific about what is missing. “With an additional system in the ROS the visit would have coded as….” Or, “Please document a comprehensive exam when billing a 99222.” Be specific and positive.
If there are services that are always bundled, tell the provider. If a procedure is missing something critical, such as the length of the excision, let the provider know. And, if there are services documented that weren’t billed, providers always want to know that.
And I’m going to say it again, we share the same goals of providing medical care and keeping the doors open.
MLN006764 August 2023 p. 15