This article offers techniques you can employ to optimize your billing, underscored with examples of lessons learned by other physicians. Though many of them aren't primary care practices, their experiences resonate across all practice settings.

PRIORITIZE INTERNAL COMMUNICATION

In one instance, a physician regularly lost his temper with his coding staff for their billing practices. Intimidated by his tactics, they always billed as he demanded. But because he did not understand coding rules, he routinely underbilled in some areas and put himself in violation of medical necessity and bundling rules in others. He was a salaried employee, and with his denials and underbilling, wasn't making his numbers. He lost his $7,000 bonus that year.

For large practices, communication problems may take a different direction. Physicians may rarely talk directly with coders or billers, says Terrance Leone, consultant and owner of Catamount Associates LLC, in Clifton Springs, New York. "The coder relays a question to her supervisor, who relays it to a designated clinician, who relays it to the physician. The answer is returned along the same path. This is not the way to solve problems in documentation, coding, or billing. Direct communication and team building are critical to successful reimbursement."

The need for communication is echoed by Stephen L. Cheng, MD, CM, MSc, FRSCS, an orthopedic surgeon at Kaiser Permanente in Cleveland. Medical coders within his organization are required to be certified by the American Academy of Professional Coders or by the American Health Information Management Association. Cheng says that coders and physicians regularly work together to refine the pick-lists used by his office's electronic health record system.

"With the [EHR], there is the need for coders with a high level of understanding of coding, clinical practice, and the [EHR] to develop the [EHR] database and refine the tools to assist physicians in selecting the correct codes," he says. "There also remains a tremendous amount of education to be done, as frequently coding concepts remain murky and not easily conceptualized by physicians."

LISTEN TO YOUR TEAM

Because the nuances of reimbursement are complex and because the regulations are constantly changing, physicians don't have time to keep up with the status quo of coding compliance. But you do have time to listen to your team.

"In a urology practice that I evaluated, physicians refused the advice of their certified coding staff, who attempted to point out that the [EHR] system implemented by the practice was recommending erroneous E&M service levels," says Michael D. Miscoe, a medical coding and compliance consultant who owns Practice Masters Inc. of Central City, Pennsylvania. "As it turned out, the [EHR] system was undercoding established patient services by one level, and new patient and consultation services by at least one level—and in many cases two." The actual loss to the practice for the one-year period of the audit was in excess of $50,000. Although undercoding can be a technique to minimize post-payment liability, it is a very expensive one.

"In an alternate case," Miscoe says, "a cardiology practice's reliance on the [EHR] system's suggestions resulted in upcoding. Because the physicians had more faith in the computer-generated result than they did in their own coding staff, the coders were hesitant to raise their concerns with the physicians." An independent audit validated the concerns of the in-office coders and resulted in the practice having to self-disclose about $25,000 in overpayments.

"The physicians at this practice learned a very expensive lesson: Just as a computer can't replicate the didactic analysis of a physician, a computer cannot replicate the complex analysis required for correctly coding services," says Miscoe.