Discover How to Avoid Frustration Coders and Physicians Face
If you’re a medical coder or coding administrator feeling frustrated by “incomplete and nonspecific” documentation…
Or fed up with patient charts “replete with errors and discrepancies”…
Or you despair of bridging a “communication divide” between coders and physicians…
…you’re not alone!
These frank descriptions come from Dr. Karen Tang and colleagues’ interviews with 28 medical coders. They spotlight what those coders see as “physician-related barriers to producing high-quality administrative data.”
How can coders and physicians move past these barriers?
Physicians didn’t take medical coding and billing courses in med school. “The truth is,” Dr. Adele Towers writes for AHIMA, “that most physicians have no idea what CDI [clinical documentation improvement] means and why it should be important to them.”
That’s why the best way to get physicians to help you achieve improved coding is to show how and why what you do helps them.
As Todd Kislak writes for H&HN, “[A]nswer the ‘What’s in it for me?’ question that physicians often ask silently or aloud. Do this for your physicians and watch them improve their documentation.”
Here at MDCodePro, we want to be a resource for coding professionals looking for better ways of working with physicians. We know coders frequently feel frustrated by the difficulties they face getting enough details from doctors for choosing a specific code.
Sometimes the “not enough detail” affliction can feel like a chronic condition no coder can cure! But here are a few ways to move past physician-coder frustration toward improved documentation—and toward more accurate and regulatory compliant coding, as well as more revenue for the practice.
Implement Standard Query Procedures
You’re more likely to get the details you need from doctors if you present your follow-up questions the same way every time.
Models for doing so exist. As the AAPC points out, CMS “has adopted query guidance for hospital needs, but there is nothing in the guidance to indicate queries are only for hospitals. So why not use them in the physician office?”
Stick with standard query formats—open-ended, multiple choice, and yes/no—use standard templates, keep queries brief and relevant to a specific date of service, and ask in a timely fashion (the AAPC recommends within 30 days of the initial documentation.)
Be certain you’ve told physicians about query practices you adopt, and don’t be reluctant to remind everyone about standard query protocol once in a while.
Stick Close to Physicians
No matter how much you enjoy your work, you don’t want to sit behind your computer with doctors’ notes and patient charts all day long, right? Why not be where the action you translate into diagnostic and billing codes is taking place?
“Sometimes,” professional coder Mary Pat Whaley told Physicians Practice, “physicians can… benefit from having a coder shadow and scribe the [patient] visit in addition to the physician’s documentation to compare what each comes up with. You would be surprised how often a physician forgets to say, ‘I reviewed the… lab results, X-rays, consultation report, etc.’ It’s something very simple, but, if it wasn’t documented, it wasn’t done.”
If shadowing doctors during visits isn’t an option, you may still be able put yourself in a better place—literally—for catching documentation mistakes. One coder told the AAPC sitting near physicians’ offices “has helped me out tremendously as I can hear my doctor dictate his surgeries, office visits, etc., and will catch some things before they are billed out incorrectly.”
Take Your Teaching Role Seriously
You may not see yourself as an educator, but you may be the closest some physicians ever come to taking a medical coding and billing course.
Take and make opportunities to tell them what information you need from them and especially why: so patients receive the most appropriate care possible, so records of the care comply with all regulations, and so the practice receives all the revenue it deserves for providing the care.
Being a teacher doesn’t mean being condescending, but it does mean being direct. “Physicians are by nature independent thinkers,” writes Dr. Towers, “and will expect a very concise, clear reason to change documentation habits.”
Physicians “will, and do, support CDI efforts,” write Glenn Krauss and Dr. Jeffrey Epstein for the Association of Clinical Documentation Improvement Specialists, “when such efforts are distinctly tied to excellent care and achieving the best outcomes for their patients.” The more specific and substantive your explanations, the better.
Offer Physicians a Realistic, Relevant Medical Coding Training Program
While physicians don’t have time to meet the same medical coding and billing certification requirements professional coders meet, their ongoing education can include training in medical coding—especially when that training is accessible, flexible, and useful in their daily work.
MDCodePro is an online medical coding and billing course and app (for desktop and mobile browsers) designed to bring that kind of coding education within your physicians’ reach.
Best of all, a vigorous emphasis on improved documentation runs through it all. The MDCodePro methodology will make the doctors you work with better at thinking through the patient’s risk and their medical decision-making in their notes—which means they’ll give you, in the right way, more of the information you need to make the best coding calls for your practice and its patients.
See for yourself how MDCodePro can help clear away those frustrating barriers physicians and coders too often face. Sign up for your subscription today.