Remove the “A”

Featured coffee – Mystic Monk Thanksgiving Blend

Some apprentices may be under the impression that having the “A” removed will make it easier to get hired.  It’s not the “A” on your resume; it’s the lack of experience that is preventing you from being hired.

Let’s consider a CPC-A^®.  It doesn’t matter a “newbie” scored high on the certification exam.  The exam is not real-world coding.  On the certification exam, you have a one in three chance of selecting the correct answer and only have to score 70% to obtain certification.  In the real world, you have one chance to abstract the correct codes and must maintain at least 95% accuracy.

Let’s first define an apprentice.  According to Merriam-Webster, an apprentice is “one who is learning by practical experience under skilled workers a trade, art, or calling”¹

I hear the frustration from you who have the designation of an apprentice, but you have to understand the other side.  It requires considerable investment for a company to hire an apprentice.  The company bears the financial and administrative burdens of paying an apprentice to learn real-world coding.  That means the apprentice’s work has to be reviewed before it goes to billing, and feedback has to be given to ensure mistakes are not repeated.

If you are fortunate to receive an employment opportunity, don’t criticize the low pay.  Be thankful that you found an organization willing to give you a foot in the door job.  The company is paying you to learn how to code and is then paying a more seasoned coder to validate your work and provide feedback to you.  This means the organization’s production is lower, and claims submissions and payments are delayed while compensating two people to code the same records.

I was requested to perform audits and coder education for a coding vendor because of significant errors identified by the vendor’s client, and the contract was in jeopardy.  The most significant mistake was by an apprentice who assigned a diagnosis code of Plague to a patient when the physician documented Plaque.

It was not the apprentice’s fault.  Her coding was not reviewed, and as a result, she was not given feedback on her work.  Her coding went straight into the client’s system for not just billing, but also for statistics reporting to other agencies.  The diagnosis of Plague triggered an alert in the system.  It’s an epidemic disease that causes a high rate of mortality and must be reported immediately to the Centers for Disease Control (CDC).

All of this vendor’s contracts were production-based.  They were paid according to the number of records coded.  They did not have a training budget or time to teach someone with no prior coding experience.  To maintain their contract, they had to hire me for quality control and coder education.  Unfortunately, it was not cost-effective for this vendor to recruit more apprentices.

So, don’t focus on removing the “A.”  In my opinion, having the “A” removed without having real-world experience only satisfies your ego, not your career goals.  Concentrate on getting that foot in the door job no matter how low the pay and gladly accept the pay rate that is offered.  Remember, the company is actually paying you to learn!

 

CPC-A^® is a trademark of AAPC

¹https://www.merriam-webster.com/dictionary/apprentice

https://wwwn.cdc.gov/nndss/infographic-intro.html

 

 

 

 

 

But, we’ve always done it this way…

Featured coffee – Caramel Pumpkin Macchiato

Have you ever questioned why someone does something a certain way, and the only response is, “that’s the way we’ve always done it”?

Well, in the coding world, that’s not good enough, and it raises red flags.

For example, a coder always assigns 99213® no matter what is documented for an established patient.  When asked why, the response is, ‘we always do that, and it’s never been a problem”.  Others chime in and say that if medication is prescribed, it’s a level 3.

Well, dear coders, now you have a problem, and I’ll inform you why.

The level of E/M reported for professional-fee services is driven by the documentation of three key components – History, Exam, and Medical Decision-Making, unless documentation supports coding based upon time.

We know that an established patient visit only requires documentation of two of the three key components; however, the coders are saying that the encounter supports a level 3 based only upon prescription medication.

There is not a coding guideline to support their rationale.  The coders are doing it because it’s always been done that way in this practice.  Sometime in the past, someone made this decision, and everyone is following that internal rule.

Unfortunately, the practice has not been audited by an independent auditor or third-party payer.  It’s unfortunate because they have not been forced to question the decision to create their own guidelines that are contrary to coding conventions.

Absolutely, I’m frustrated with the coders.  As certified coders, whether through AAPC or AHIMA (the major coding certifying bodies), we’re bound to uphold our organization’s Code of Ethics.

According to AHIMA®,  “Coding professionals shall:  2.1. Adhere to the ICD coding conventions, official coding and reporting guidelines approved by the Cooperating Parties, the CPT rules established by the American Medical Association, and any other official coding rules and guidelines established for use with mandated standard code sets.”

According to AAPC®, “We are responsible for being competent and knowledgeable. We are responsible for giving our employers the benefit of our knowledge and advice, even though this advice may not be followed.”

As professional coders, we are obligated to assign codes based upon guidelines.  We are not to read more into or disregard anything within the guidelines.  If we are requested or instructed to code in a way that we recognize is noncompliant with coding or payer-specific guidelines, our responsibility is to inform the requestor of the correct coding guidelines.

Accordingly, just because you’ve always done it that way doesn’t make it the appropriate way (especially if you’re not following coding guidelines).  You may be doing it wrong, and you don’t even know it because you haven’t been audited.

Audits may result in penalties that range from refunds to fines and program exclusions or even prison terms.

If you are assigning codes based upon office policy, verify that your policies comply with coding guidelines.  Review the Compliance Program Guidance for Individual and Small Group Physician Practices developed by the Office of Inspector General (OIG).

According to OIG’s guidance, in Section II. Developing a Voluntary Compliance Program A,  The Seven Basic Components of a Voluntary Compliance Program,  “The physician practice written standards and procedures concerning proper coding reflect the current reimbursement principles set forth in applicable statutes, regulations and Federal, State or private payor health care program requirements and should be developed in tandem with coding and billing standards used in the physician practice. Furthermore, written standards and procedures should ensure that coding and billing are based on medical record documentation. Particular attention should be paid to issues of appropriate diagnosis codes and individual Medicare Part B claims (including documentation guidelines for evaluation and management services).”

If your defense is, “that’s the way we’ve always done it, and it’s never been a problem,” please click on the hyperlinks to learn more about why it’s a problem.

 

CPT® is a registered trademark of the American Medical Association

AAPC® is a registered trademark of AAPC

AHIMA® is a registered trademark of American Health Information Management Association

 

Stand on the Guidelines

Featured coffee – Butter Rum Flavored Coffee

I went on-site to do a provider education session for the site’s coder.  My responsibility was to reinforce the feedback previously provided by the coder.  I performed a brief review and scheduled the training session.

I began the session by reviewing the importance of compliant coding and coding guidelines.  I next went into my findings.

First on the agenda was documentation required to support consultative services.  I noticed a gentleman came in late, and he took a seat in the middle of the room.  I never broke stride and continued my discussion.   This gentleman interrupted me and asked very loudly, “Young lady, are you calling my physicians liars?” I was on the first “R” – the request for opinion or advice!

I felt like the room went pitch-black with spotlights only on the two of us.  I told him I was not calling his physicians liars, but the documentation that I reviewed did not support that they were requested to give an opinion or advice, which is the first required “R.”  According to the documentation that I reviewed, the care of the patients was transferred to his physicians.

The crowded room was completely silent, and the tension was palpable.  We were going back and forth!   I think I blacked out, but my project manager recapped the nightmare for me later.  I looked at the coder, and I wanted to strangle her because she should have addressed this with the physicians.

I was standing behind a podium, and I actually took my shoes off because I was settled in for the fight! I broke down the issue to the nth degree, and I included examples from his physicians’ documentation.

The hour was a blur.  My project manager told me I told him I was OIG (I’m really not).  When the session was over, he came over and shook my hand.  We walked out together, and he thanked me for the feedback.

The next day, I received a call from my project manager. She told me that the Chief of Medical Staff for the facility (the gentleman in the middle of the room) sent her an email to thank me. He also requested I return to provide quarterly updates for his physicians.