Jarrod Shapiro, DPM
Practice Perfect Editor
Mountain View
Medical &
Surgical Associates,
Madras, Oregon
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The Art of Coding
If medicine isn’t complicated enough with the need to understand the physiology of the human being, psychological issues, medications, and various surgical techniques and fixation devices, the successful podiatric physician also needs to be an expert on coding and billing. It’s simple: without utilizing the correct codes and billing procedures you’re working for free. Simple, right? If only….
During the conversion to a new office management software system it came up that all of the physician providers in my clinic are undercoding, myself included. This conclusion was based on a comparison between the number of E/M codes documented for each physician compared with national benchmarks. I have to say I was moderately surprised by the findings as I’ve been in practice for about three and half years and had some coding training in residency. Of course, I know no one’s perfect, and we all have room to improve, especially when it comes to coding.
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What makes coding so complex? This requires a multifactorial answer. The first part of the answer lies in the general lack of training physicians receive in the coding and billing process. We’re so immersed in the science of patient care during residency that our programs neglect this aspect of our training. Some residency programs, such as the VA, provide even less exposure than the rest. Unfortunately, because of the system in which we practice, we’re required to master this skill in order to make any money in the real world. I don’t blame programs for not teaching it or residents for not wanting to learn. Compared to the medical aspects of our jobs, learning coding is like reading stereo instructions.
Second, the ICD-9 (soon to be ICD-10) and CPT coding systems are quite complex and constantly changing. Not only do we have to diagnose disease, but we also have to remember the specific code attached to it. Hallux valgus? 735.0. Plantar fasciitis? 728.71. Diabetes? 250.0_. Diabetes with neuropathy? 250.6_. Poorly controlled diabetes with peripheral neuropathy? 250.62. It goes on and on. If you use the “wrong” diagnostic or procedure code you may not be reimbursed. Performing a bunionectomy? The code depends on the type of procedure. Don’t mistakenly code 28296 (distal metatarsal osteotomy) when you actually performed a 28290 (Silver bunionectomy) or you’ll get in trouble by the HIPPA police – Yes, I think there are actually little police running around making sure we don’t violate HIPPA, and they moonlight as coding police!
Now, this is not even mentioning Evaluation & Management codes which cover all of the "nonprocedural" codes. Each code is based on multiple factors, making it somewhat difficult to rapidly code a new patient or follow-up visit appropriately. See the table for a determination of E&M codes.
Code |
Severity |
Time |
HPI* |
ROS** |
PMFSH*** |
Exam¥ |
Decision Making¥¥ |
99201 |
Low |
10 min |
Problem focused (1) |
0 |
0 of 3 |
Problem focused (1-5 elements in 1 system) |
Straightforward |
99202 |
Low to moderate |
20 min |
Expanded problem focused (1) |
1 |
0 of 3 |
Expanded problem focused (6 elements in 1 system) |
Staightforward |
99203 |
Moderate |
30 min |
Detailed (4) |
2 |
1 of 3 |
Detailed (2 elements in 6 systems or 12 elements in 2 systems) |
Low complexity |
99204 |
Mod to high |
45 min |
Comprehensive (4) |
10 |
3 of 3 |
Comprehensive (All elements in 9 systems or 2 elements in all systems) |
Moderate complexity |
99205 |
Mod to high |
60 min |
Comprehensive (4) |
10 |
3 of 3 |
Comprehensive(All elements in 9 systems or 2 elements in all systems) |
High complexity |
|
99211 |
Low |
5 min |
0 |
0 |
0 of 3 |
0 |
Staightforward |
99212 |
Low to moderate |
10 min |
1 |
0 |
0 of 3 |
1 |
Staightforward |
99213 |
Moderate |
15 min |
1 |
1 |
0 of 3 |
6 |
Low complexity |
99214 |
Mod to high |
25 min |
4 |
2 |
1 of 3 |
12 |
Moderate complexity |
99215 |
Mod to high |
40 min |
4 |
10 |
2 of 3 |
12 |
High complexity |
*HPI: Nature, location, duration, condition, onset, severity, treatments, radiation of pain.
** Review of Systems: Constitutional Signs, Eyes, ENT, Cardiovascular, Respiratory, Gastrointestinal, Genitourinary, Musculoskeletal, Integumentary, Neurological, Psychiatric, Endocrine, Hematologic, Allergic/Immunologic
***PMFSH: Past medical, family, social history.
¥Exam: Eyes, ENMT, Cardiovascular, Respiratory, Gastrointestinal, Genitourinary, Musculoskeletal, Integumentary, Neurological, Psychiatric, Hematologic/Lymphatic/Immunologic
¥¥Decision Making:
Straightforward: Minimal number of diagnoses or treatments, minimal data complexity, minimal risk of complications.
Low Complexity: Limited number of diagnoses or treatments, limited data complexity, low risk of complications.
Moderate Complexity: Multiple number of diagnoses or treatments, moderate data complexity, moderate risk of complications.
High Complexity: Extensive number of diagnoses or treatments, extensive data complexity, high risk of complications. |
But wait! If this isn’t complex enough for you in the middle of a busy office day, consider that if you over code you may have to pay back money you’ve received from Medicare or private insurers if you’re unlucky enough to be audited. But wait! There’s even more. Did you know Medicare has discontinued the “consultation” codes effective January 1st? This is supposed to make it easier for us, although its true purpose is to pay physicians less. But wait; there’s more yet! If you use one code too often this will set up a “flag” in the system, increasing your chances of being audited.
The third issue revolves around charting. Not only does our charting have to reflect the care we provide – which it should; I have no argue with this – but we also have to know the correct wording, which buzz words to use. Here’s an example. I see a wound care patient in the office for a neuropathic ulcer that I debrided, dressed, and offweighted. I can’t just say that, though. In order to be correct I have to include something like the following: “I performed a full-thickness excisional debridement through skin and subQ layers removing all periwound hyperkeratosis and necrotic tissue with a scalpel blade without anesthesia secondary to patient’s profound sensory loss.” Additionally, a full description of the ulcer (including the presence of necrotic tissue if present, size, depth, etc.) must also be included. I won’t disagree that it’s important to appropriately describe what we see and do during a patient encounter, but it can get ridiculous!
With all this in mind here some suggestions to help practitioners with coding appropriately and profitably.
- Chart structure. Those in practice many years may still be using the SOAP format for all notes. I suggest the modern charting method for all new patients. This is based on bullet points and makes it easy for both the doctor to determine level of complexity in coding and for the auditor to review charts. Yes, you want to make it easy for the auditor. If they have to comb through your charts they’re more likely to come down hard – they are human remember. The modern method includes the following information: Chief complaint, History of Present Illness, Past Medical history, Allergies, Medications, Surgical history, Social history, Family history, and Review of systems. A common podiatric physical exam includes: Vitals (get at least 3), Psych, Vascular, Dermatologic, Musculoskeletal, and Neurological. The SOAP format is fine for follow-up visits but be sure to include a review of systems (including pertinent negatives), a statement that the other history components have not changed since the last visit, and break the objective section into the same bullets as the above physical exam section.
- Consider upgrading to an EMR system. Good systems will have an option to calculate the coding level based on the data input during the visit.
- Use an online coding information service. The APMA website has some good information about coding and practice management. Other services such as Codingline are helpful also.
- Use a certified billing company. This is worthwhile for those who are too busy to do their own in-house billing or just hate the idea of spending a lot of time and effort on this. Keep in mind, though, that a professional biller doesn’t replace a good chart note – that’s your protection. Additionally, be sure to periodically audit your service.
- Get training. Many sources are available including the ACFAS course and AAPPM (American Academy of Podiatric Practice Management), among others.
- Follow those more experienced. Ask colleagues with successful practices to bounce questions off of them.
Unfortunately, for all my hemming and hawing the system is here to stay and the only way to win (AKA getting paid for what you do), is to know it in and out and continually search for more knowledge. For those in residency I would strongly recommend suggestion number 5. Consider the ability to appropriately code and bill that triple arthrodesis as important as the ability to do the procedure. Yes, it’s boring. Yes, it’s tedious. Yes, it’s confusing. But yes it’s very important – unless, of course, you don’t want to get paid for that hard work you do. Oh yeah, and don’t forget the modifiers
Keep writing in with your thoughts and comments or our eTalk discussion forum on PRESENT Podiatry and start or get in on the discussion. We'll see you next week. Best wishes!
Jarrod Shapiro, DPM
PRESENT Practice Perfect Editor
[email protected]
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