Stay involved by overseeing procedural coding for reimbursement

October 1, 2005

Must ophthalmologists understand procedural coding? Perhaps a staffer or even a computer program could do the job? Unfortunately, the answer today is that physicians need to remain involved, understanding and then overseeing the process in their offices.

Editor's note: Beginning with this issue, L. Neal Freeman, MD, MBA, adds a regular column on coding.

A number of coding systems for physician services are in use in the United States. We are fortunate to have a system for reporting most physician services that is designed and maintained by physicians working together as the American Medical Association's CPT Editorial Panel. Though CPT 2005 is not perfect, it is far simpler than some proprietary systems created by industry or than ICD-10 developed by the WHO.

Most procedural and diagnostic coding is straightforward. The code descriptor precisely fits the service provided, the payer recognizes the claim, and the claim is paid expeditiously. For these cases the only risk is that there is evidence that the service was provided and that the medical necessity is substantiated in the record should there be a post-payment audit. For these claims, almost any office staff member with modest training can perform the reporting, even using out-of-date coding manuals.

Unfortunately, this paradigm breaks down more often today. Problems may occur when a physician is providing an unusual service, performing a service for a new indication, employing a new technology, or working with a new payer. Many nuances to the descriptors are easily understood by the clinician, but completely obscure to the staff person. Without physician involvement, incorrect codes may be chosen or there is uncertainty and the claim is set aside.

Lack of interest?

Many physicians are not interested in coding for a number of reasons. Most ophthalmologists prefer to spend their time at work in clinical activity. Some are intimidated by a system that can charge an ophthalmologist with criminal actions. All physicians are frustrated by the lack of uniform answers to their questions, largely because of the decentralization of payment policy. Into this gap have stepped a cadre of experts who provide the best information they can about what the payer has done and is likely to do. They will be familiar with the widespread or typical problems, but may or may not have experience in your region, with your practice type, or with your payers.

Coding experts rely on your expertise to understand the service and its relationship to the code descriptors, deciding whether the service fits the code descriptor, is the service medically necessary, and applying the known payment policy. The consultant deals best with a well-informed client. Whatever advice is given, the ophthalmologist needs to be comfortable with the opinion. If it sounds too good to be true, trust your instinct.

Another area in which physicians should be active is at the level of local carrier decision-making. Participation in carrier advisory committee discussions and meeting with medical directors is a task for the ophthalmologist. Consultants can help frame the questions, but we have the expertise to advocate the policy that benefits our patients, as well as reject the policy that lacks a reasonable chance of benefit. Lastly, the doctor is in the best position to reach the medical director of a plan to discuss an issue or to appeal a denied claim.

I expect that L. Neal Freeman, MD, MBA, will promote active physician participation in coding practices in his column by drawing on his experience in clinical practice and by working to develop new codes and their relative values through the AMA's CPT Editorial Panel and Relative Update Committee. His effort will not replace, but complement, the consultants who keep up with the arcane rules of coding and billing, as well as working as confessors in some cases.