Coding is perhaps the most important thing that a doctor does, yet coding as a discipline is not even touched upon in medical school or residency. Coding costs money yet makes money, is complicated yet simple, and frustrating yet gratifying. Coding sucks, yet I love it. Coding! Coding—a word that has taken on a connotation to many physicians that puts it on par with excrement. Yet coding is as essential to growing and maintaining your practice as are your medical skills. So, as you are now solo, you must learn the following; what is coding and why is it important?
All medical diagnoses have been assigned unique numbers, the ICD-9 codes, and all medical procedures their own unique numbers, the CPT codes and coding is a method of using these numbers so that you can get paid. How is that? In order to get reimbursed from a payer for anything you do, other than from a cash-pay patient, you must submit a claim, either on a HICFA 1500 or its electronic equivalent, to the insurance company or Medicare--the payers. The claim form describes what you diagnosed the patient with and what you did for the patient in a way that can be interpreted by a computer, ie it uses numbers; the ICD-9 and CPT numbers.
ICD-9 codes are the diagnosis codes, for example acid reflux, HTN, herpes, whatever. There are literally thousands of ICD9 codes that correspond to virtually every medical diagnosis that exists. All specialties have their own ICD-9 codes; derm, ophtho, ortho, hematology, all of them. Within urology, my specialty, there are hundreds of ICD-9 codes that cover everything from hematuria to hemospermia to prostate cancer and many, many more. The numbers even allow for nuances in diagnoses, such as azoospermia from a prior vasectomy or that which results from congenital blockage or from testicular failure. As another such example, a prostate lump that is benign, a prostate lump that is malignant, and one that is suspicious--but not certainly--for cancer all have their own codes. It is actually a quite ingenious system, and one can marvel at both its complexity and simple elegance. I find it truly amazing.
The CPT codes define what you, the provider, do for the patient. For example, CPT codes cover office visits as well as “true” procedures, such as an EKG or a Whipple Procedure. The various medical, surgical, radiological, and laboratory specialties each have their own unique codes that define what they do. In urology there are codes for procedures such the cystoscopy, vasectomy, lithotripsy, and the transurethral resection of a bladder tumor for small, medium, and large tumors (all with their own codes), of course, among many others. There exist separate codes for manual urinalysis, machine urinalysis, venopunture, FSH, LH, serum rhubarb, whatever. You name it, there is a code for it, except for the unlisted codes, the -89990’s, but that is a separate story.
CPT codes are linked to ICD-9 codes. More importantly, specific CPT codes are linked to specific ICD-9 codes. This is a very important concept to grasp and master. For example, 233.6 is the ICD-9 code for testicular cancer and 54300 is the CPT code for testicular biopsy. These codes, actually, do not match. They are not linked. This is because the 54300 biopsy is done for 606.8 or 257.8 only, infertility codes, not for 233.6, the cancer code. Submitting a claim for a 54300 with a 233.6 code would result in either a non-payment, or payment of a lower amount. As another example, varicoceles, 456.4, which can cause infertility in men, are corrected with a varicocelectomy, a 54500 code. Not all patients have insurance that covers infertility, 606.1, but I have yet to encounter the insurance plan that does not cover varicocelectomies done for 456.4. Therefore, if you want to get paid for a varicocele repair by the insurance company, you best use 456.4. The ICD-9 code for shortness of breath may allow you to do an EKG, while the code for a runny nose will not. And so on. If you are getting chest pain while reading this, don’t. It is actually not so hard and most inexpensive practice management billing software can link ICD-9s with appropriate CPTs. In addition, you’ll get so good at it yourself that it’ll become second nature.
Office visits are billed using ICD-9 and CPT codes as well. The ICD-9 covers the diagnoses and the CPT codes cover the level of complexity of the visit. What is the level of complexity of the visit? In the United States, there exist 5 levels of complexity for an office visit, be it a new patient, a consult, or an established patient visit. From least to most complex, levels 1 through 5. For Medicare, and in theory for the commercials, you get paid more for a 5 than a 4, a 4 than a 3, and so on. But what defines the various levels. This is determined by 3 factors: the documentation of certain elements in the history, physical exam, and complexity of medical decision making. The CPT coding books that are published by the AMA describe what elements are needed for each level of service. For the history and physical, correct and accurate coding is actually straightforward and can be template driven since the coding book defines the number of elements that must be documented during the encounter to reach each level of complexity. However, the rules defining correct coding for medical decision making are written in a much vaguer manner, perhaps purposefully. And therein lies the rub, because accurate coding requires documentation that supports all 3 elements of the encounter. Since the “complexity of medical decision making” is, in essence, a judgment call, all coding/billing is therefore, a judgment call. What might be a level 3 to you could be a level 2 to someone else or a level 4 to yet another person. All billing is a judgment call.
This fact has 3 major implications. First, payers, including Medicare, can come back at anytime, audit your charts, and demand refunds if they don’t agree with your coding. Their “judgment” and yours could differ. Medicare actually considers this fraud. Second, the “audit proof” coding program is a myth. Third, it allows for down-coding, a ubiquitous practice amongst the commercial payers that involves automatically reimbursing you for a lower level of service than that for which you billed. Read this paragraph again, because understanding it could save you a ton of money.
Many of the commercially available EMR programs offer packages, expensive ones, which have the ability to extract information from your electronic notes and generate a bill. They actually code for you. The companies claim that their programs can “up-code” the encounter and are “audit proof.” They will show you charts and graphs and supply you with testimonials that support their claims. They will use a term “ROI”, return on investment, to convince you to spend a huge sum of money on their product. They will offer you attractive leasing options. But because you read the above paragraph, twice, you won’t fall for it. All billing is a judgment call, and judgment is a uniquely human trait. Computers do not make judgments.
ICD-9 and CPT codes, the actual numbers themselves, are owned by the AMA—the American Medical Association. The AMA sells the codes to companies that use them in billing software, billing books, etc, and the AMA does quite well financially from this arrangement. The AMA coding committees meet periodically to add, subtract or modify the codes. The changing medical codes reflect the advance of medical practice—or its decline, depending on how you look at it.
Coding is a huge industry that did not exist 25+ years ago. Coding personnel consider themselves to be professionals and they have their own societies and professional organizations, just like doctors. Coders have meetings on a regional, sectional, and national level and even have their own version of CME, just like doctors. Coders and billers can work for doctors’ offices, billing services, insurance companies or the government. They do quite well, and a good one is well worth their salary. Some doctors specialize in coding and billing, similar to doctors who specialize in oncology or ID or ED, etc. These doctors travel the country lecturing other doctors and billers and coders on how to bill and code. Many people consider the coding and billing industry to be a huge waist on health care’s expenditure, and it has estimated that as much as 45% of spending goes to it. But it is here to stay and if you accept and learn it, you’ll come to appreciate and perhaps even admire it.
I hoped you liked the post.