Physician's Coding Strategist-Same coders handle both physicians and hospital

Accuracy, consistency are achieved

If the pilot project of a Wisconsin research and teaching hospital catches on, the distinct division between hospital services coders and physician fee coders could soon begin to blur, leading to one coder handling both sides of the coding process.

The University of Wisconsin Hospital and Clinics (UWHC) in Madison is using coders who handle both the professional fee side and the hospital services side of coding patient encounters. The three coders at UWHC, who have the job titles of medical center coders, have started their hybrid coding in ambulatory services. Two of them code for the hospital emergency department (ED) and one codes for a dermatology clinic.

"This started out to provide consistent data so that what was coded for hospital services was consistent with what was coded for the physician services," says Bill French, MBA, RRA, director of health information services at UWHC, which includes 80 clinics. "As Medicare became more and more of an issue, [it ensured] accuracy on both sides."

When discussions about creating a new type of coder began about six years ago, health information professionals at the hospital and the Univers ity of Wisconsin Medical Foundation, an affiliated physician organization, saw changes in the wind. Not the least of these was the eventual spread of prospective payment systems from inpatient to outpatient settings.

"We knew that APGs [ambulatory payment groups] are down the road and wanted to make sure we had good-quality coding for the hospital side," French explains. "And we wanted to base the coding on the actual documentation, rather than on what somebody checked off a list or what the physician may have indicated verbally but did not document."

UWHC expects that coders who have access to both the physicians and their documentation will achieve greater accuracy. "Coders can't just discuss something in the hallway with the doctor. They have to complete the documentation so it accurately reflects what was done to the patient," French says.

Source documents are within easy reach

To bring them closer to patient encounters, UWHC medical center coders are located in the departments for which they code both the hospital and physician services. The two emergency department coders work near the ED, while the third coder is located at the dermatology clinic.

That way, the source documents — narrative, lab results, radiology results, or any diagnostic tests that are done — are within easy reach, French explains, and the coders are in close proximity to the physicians.

"You want them to have good contact with the care providers. You want good communication, and then they also have to have access to the documentation," French says.

The nearness to caregivers will be a key component of the medical center coders' success, predicts Rita Scichilone, MHSA, RRA, CCS, CCS-P, PMM, a practice manager in the coding products and services division with the Ameri can Health Information Management Association (AHIMA) in Chicago. Because medical center coders will be working closer to the care setting, they will be "more in tune than people in medical records. They'll get a lot more cooperation from physicians for the information that you need to code for the facility."

In addition, "With one pass through the record, gathering all the information needed for hospital and professional fee coding, the big advantage is consistency of data; you would never have codes disagree. They're constantly in that chart reviewing and updating," she says.

AHIMA offers separate certifications for hospital and physician office coders: Certified Coding Specialist (CCS) for inpatient encounters and Certified Coding Specialist—Physician-based (CCS-P), a new certification that is about a year old.

Coding moves into 'hybrid world'

The idea of one coder handling both sets of coding systems gets a positive response from Sue Prophet, RRA, CCS, director of classification and coding for AHIMA. "It's a good idea because we're sort of moving into a hybrid world where the lines are getting blurred, and more and more you see people doing more duties and getting involved in coding in physicians' offices in integrated delivery systems."

"There could be a day where . . . it became one credential and everyone had to know coding in all areas. It's not like that in coding right now," she explains.

"There are still rather defined skill sets that are somewhat different on the two sides for physician services vs. billing for the DRGs [diagnosis-related groups] on the inpatient side. There is enough delineation to warrant two credentials, but if you're working in two areas, there is certainly nothing to preclude people from getting both credentials."

So far, the pilot program gets high marks, French says, though results haven't been quantified. "There are some efficiencies to be gained," he says. "You do find lost charges that may have been coded but not charged for and vice versa."

The pilot is working so well that UWHC plans to expand to 26 medical center coders, each coding both the hospital services and the physician fee sides of patient encounters — as many as 15,000 to 20,000 encounters annually.

The three medical center coders at UWHC are employed by the medical foundation, although they could just as well be employed by the hospital, French says.

The medical center coders are co-supervised by a manager from the physician organization and a manager from the hospital. As the number of medical center coders grows, UWHC plans to hire a separate supervisor to manage them. Under the expansion plan, the supervisor will handle training and education on compliance issues, including making sure the coders are aware of coding changes and the latest HCFA and carrier regulations.

"We're making sure they get all the material and that they understand it, and the supervisor will audit their coding to make sure they can demonstrate the coding," French explains. The supervisory tasks currently are handled by the two co-managers.

Although the medical center coders are expected to possess a larger body of knowledge than either hospital or physician services coders, their salaries are not initially higher than those of their colleagues, French says. "We are addressing pay issues," he adds.

Moving forward, medical center coders will be divided into three levels based on skill sets. "We're breaking it down the way we expect the APG system to break down," he explains.

Level one medical center coders will handle mainly medical visits where no procedures are performed. Level two coders will code roughly three to five medical specialties where procedures could be involved. Senior coders will have the knowledge to "code everything," French says. "Obviously, we'll have more people in the first two levels. The senior level is going to be someone who has been around for a long time and can basically go anywhere and code."

Coders will stay with same doctors

When more medical center coders come on board, they'll be assigned to handling hospital services and physician fee codes for a particular area. "We're not going to play musical coders," French says. "The plan is, the coders will basically stay with the same group of doctors until they are reclassified [to a higher level] and go on to [code] surgery." That way, they'll be able to develop a rapport with a particular group of doctors, he adds.

The plan sounds great to Scichilone, but she wonders where health care providers will find enough coders with the breadth and depth of coding knowledge to handle both the hospital coding guidelines and physician services guidelines. "Where are you going to find these wonderful people? It's tough to find good qualified coders now," she says.

The answer lies in keeping lines of communication open with local education centers, French says. "We have improved our communications with local and regional associate's-level and bachelor's-level health information programs, as well as local community college programs."

Training current employees also will ensure a solid foundation of knowledge, French says. To master all the necessary information, "You do have to know about the two sets of coding guidelines. But you're going to start out with a small number of specialties, and then you're going to progress. You'll do medical [coding], then some medical and some surgery [coding], and so on. The trick is going to be training these people on how to code in both sets of codes. The two coding managers will develop the training."

UWHC is planning to use implementation teams to ensure that the expansion of the use of medical center coders progresses smoothly. The teams will consist of hospital medical records; coding management; and representatives from fiscal management, human resources, and information systems. Physicians, physician practice managers, and their administrative staff will round out the teams from the Medical Foundation side. The implementation teams also will monitor and audit the pilot project's growth, French says.

Next on the roster of hospital services to receive the benefits of medical center coders: oncology, neurology, transplant, surgery, ENT, orthopedics, and urology.