1. Taming the Dragon: How to teach residents to code office visits
John Rowe, MD
David Mouw, MD
Blake Fagan, MD
April 29, 2006

2. Why is this so hard? It’s boring It’s irrelevant
Residents feel the need to learn medicine, and not “superfluous stuff”
They didn’t go into Family Medicine to do paperwork
Faculty themselves lack skills in this area

3. What will you get from this session
Know four ways to teach accurate coding of office visits
Develop a system for monitoring coding accuracy
Appreciate the impact that improved coding has on charges and collections.
Focus of this talk: coding office visits. Clearly one has to use valid ICD9 codes as well…but that’s another talk.

4. What methods do you use to teach coding of office visits to your residents?

5. A Multi-pronged approach
Didactic sessions
Sit down time with business office coding specialist
Simplified criteria for documenting level 4 visits.
Coding cases
Office Consulting (Precepting) with focus on how the visit is coded
Monthly feedback on office visit coding

6. Didactics
Ever since coding guidelines for office visits were published in the 90s.
Guidelines are reviewed
Residents would hopefully learn by coding their own notes.
This didactic approach, by itself, did not make a significant dent in overall coding accuracy.
We will focus on the other things we do.

7. Our journey from there to here

8. Our coding levels, 2000

9. Employing a Certified Coder
Sent a Business Office staff person to coding school
Started doing pre-billing audits of faculty Medicare charts
Developed a process for giving feedback to faculty, providing data, and sit-down sessions with the coder

10. Audit Results
Audited 13% of Medicare visits by faculty (998 notes) from Jan – June 2001
Charts needing to be down coded %
Amount subtracted $1,350
Charts needing to be up coded %
Amount added $10,809
Total additional charges for these charts $9,459

11. Total Potential Increase in Charges
This audit reviewed 3.25 % of all visits
If this were extrapolated to all visits in that 6 month period, the potential increase in charges would have been $291,046
Coding accuracy was 56% according to our certified coder.
Thus it was clear that we needed to improve coding by all providers in the practice.

12. Certified Coder’s role in Education
Meets with each first year resident to review their notes and provide direct feedback
Provides feedback data to all physicians regarding their CPT and ICD 9 coding accuracy.
Meets with any physician who needs help

13. Tools we use AAFP pocket coding guide
Simplified approach to documenting level 4 visits (developed in house).
Coding cases: notes from EMR to be coded by individual providers, and then discussed in small groups. The cases demonstrate frequent errors noted on chart audits

14. Pocket Guide to the Documentation Guidelines

15. Simplified Coding of Outpatient Visits
Most residents and faculty can’t keep track of the complete coding rules.
Streamlined approach: know the easiest (and easiest to remember) way to document levels 3, 4, and 5 visits.
Which 2 of 3 parts of the documentation for each type of note.
Know the minimal requirements for a level 4 visit documentation; this is key.

16. SIMPLE GUIDELINES FOR CODING OF OUT PATIENT VISITS
Rule of 2/3’s for established patients
Counting bulleted exam items impossible
Decision making for level 5 too rigorous for outpatient setting.

17. SIMPLE GUIDELINES (con,t)
History and A/P for level 3 Vs 4 visits.
Two keys to enabling level 4 coding.
1) Current Rx list in all notes for PMSFH.
2) So, it boils down simply to the physician thinking about the # of problems covered.

18. It’s better to know how to code
Tools we don’t use, yet.
EMR coding help
We use an EMR, which definitely helps improve our documentation, but many providers dictate their notes, and do not enter info into the fields that are used by the computer to code a note.
EMR coding software has difficulty with evaluating decision making, which is often a key element.
It’s better to know how to code

19. Coding Cases These are actual documented office visits from our EMR.
Cases are developed collaboratively by our certified coder and a faculty member.
Clinic teams (2 faculty, 6 residents) are given these office visits as unknowns to code.

20. Coding Cases (Continued)
Each case demonstrate one or more particular point(s) about coding office visits.
A complete explanation of the correct code is discussed after everyone commits to their own answer.
Clinic teams compete to see who can best code the unknowns.

21. Coding Cases (Continued)
Lets see how you can do on an unknown coding case.
We will display an office note, and then ask for a show of hands as to what you think is the correct code.
Then we will tell you what we think is the answer, and why.

22. Here we would project a documented visit, or maybe two, and then go over the answers

23. What code would you give this note?

24. What elements does it have?
HPI
ROS
PFSH
Exam
Decision Making
Overall code 4
None
More than 6 ,< 12
Moderate complexity
99213
If med list was there ,it would be a level 4

26. What elements does it have?
HPI
ROS
PFSH
Exam
Decision Making
Overall code 4 3
Med list + smoking
12 (hard to count)
Moderate complexity
99214

27. Feedback to doctors

29. CPT Coding Data

30. CPT Coding Data

31. Results of our efforts.

32. 26,448 established office visits per year
The bottom line
26,448 established office visits per year
2000 level Dif
% %

33. Difference between level 2 and 3 is $20
Results is $457,590 increase in total charges

34. Audit the auditor
To assure that our coder is accurate, we do an external audit 4 x per year, when we select a team, and send charts from each of the providers. Over the past 2 years, she has achieved % accuracy

35. Questions and Discussion