Fam Pract Manag. 2002 Jan;9(1):14.
Coding & documentation: No harder than biochemistry
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To the Editor:
You recently quoted a study which concluded that “the complexity of the CPT guidelines and physicians’ limited coding training accounted for the substantial rate of coding errors” [Monitor, September 2001, page 25].
As a “retired” physician with a second career in coaching physicians in documentation and compliance, I take exception to the comment that the CPT rules are complex. Anyone who passed biochemistry can master the documentation guidelines for evaluation and management (E/M) services in one to two weeks with simple aids such as those previously published in FPM and/or with personal coaching.
The article also stated that physicians’ limited coding training accounts for the error rate found in the study. I maintain that we aren’t coders, but we are documenters. With appropriate documentation, we can demonstrate the value we provide to our patients and receive proper reimbursement. The problem I have seen after auditing thousands of my colleagues’ records is that we are poor documenters. That is the reason for our errors.
Let’s stop whining and learn the rules of the game. They are relatively simple. Only by knowing the rules and following them will we be winners!
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