Undercoding could be costing family physicians $100,000 or more a year, and research shows FPs bill for 1.08 fewer patient problems per encounter than they actually treat. Coding correctly may be the most important thing family physicians can do to improve their bottom lines.
Susan Callaway, C.P.C., says inaccurate coding runs rampant in family physician offices. "I would guess that about 85 percent of the practices that I go into have some significant problem in one area or another in understanding how to use their codes correctly," said Callaway, a 23-year coding veteran from North Augusta, S.C. "And that always translates into money problems."
Getting Paid for Your Work
Code Correctly, Document Diligently
By Sheri Porter
12/15/2005
Just how much money? Callaway estimated that if just 25 percent of a physician's evaluation and management visits during the course of a year were undercoded by one level, "a four-physician family medicine practice could lose as much as $100,000."
Sound impossible? A check of CMS' Medicare physician fee schedule shows a payment difference of more than 57 percent between a Medicare visit coded 99213 and a more complex level visit coded 99214. In real dollars, depending on the geographic area, that could mean a loss of around $26 for every undercoded 99213.
Historically, family physicians tend to undervalue their services, said FP Thomas Felger, M.D. Felger teaches residents about coding as part of the practice management curriculum at the St. Joseph Regional Medical Center Family Medicine Residency Program in South Bend, Ind. He often reminds residents that providing E/M services -- a staple of family medicine -- takes time and effort.
FPs treat many disease processes and multiple comorbidities, and they need to understand coding techniques, such as using the modifier "-25," to account for multiple problems in one visit, said Felger. "If a patient comes in for high blood pressure and the physician ends up taking off a skin lesion, there are correct ways to get that billed and paid for."
A study published in the September/October 2004 Annals of Family Medicine concludes that family medicine involves the concurrent care of multiple problems not adequately reflected in billing data. In the study -- "How Many Problems Do Family Physicians Manage at Each Encounter?" -- family physicians managed an average of 3.05 problems per encounter, noted 2.82 in the chart and recorded only 1.97 when billing.
The study's conclusion did not surprise lead author John Beasley, M.D., professor of family medicine at the University of Wisconsin School of Medicine and Public Health, Madison.
"Talk to any physician out there in the trenches," said Beasley, "and every one of them will tell you, 'Well yeah, I don't bill for everything I do.'"
Physicians don't want to take the time to look up codes, said Beasley. "The diabetes, the hypertension and the depression will get you paid, so you don't bother to bill for the other two or three things." Medicare's claim form only allows four codes per visit anyway, he added.
While accurate coding can be a challenge for busy physicians, there's another factor at play, said Robin Linker, C.P.C., C.P.C.-H., C.P.C.-P., C.H.C., president of a national consulting firm and CEO of the Rocky Mountain Healthcare Institute. Primary care physicians often undercode E/M services for fear of an audit, she said.
"Physicians feel like they're safer if they stay in the middle-level range even when they're truly providing higher levels of service," said Linker. She cautioned that the strategy sometimes backfires because undercoding can trigger an audit for potential substandard care or overutilization of a particular code.
Linker advises physicians to lean heavily on the term "correct coding." "If they code correctly and document sufficiently, the levels of service will work themselves out," she said.
Accurate coding -- whether a physician is billing Medicare or a private payer -- is essential if a physician wants to be paid for all the services provided, said Callaway. "Every day you've got an insurance company cutting your reimbursement. You cannot afford to make even the most casual errors in coding."
Sound impossible? A check of CMS' Medicare physician fee schedule shows a payment difference of more than 57 percent between a Medicare visit coded 99213 and a more complex level visit coded 99214. In real dollars, depending on the geographic area, that could mean a loss of around $26 for every undercoded 99213.
Historically, family physicians tend to undervalue their services, said FP Thomas Felger, M.D. Felger teaches residents about coding as part of the practice management curriculum at the St. Joseph Regional Medical Center Family Medicine Residency Program in South Bend, Ind. He often reminds residents that providing E/M services -- a staple of family medicine -- takes time and effort.
FPs treat many disease processes and multiple comorbidities, and they need to understand coding techniques, such as using the modifier "-25," to account for multiple problems in one visit, said Felger. "If a patient comes in for high blood pressure and the physician ends up taking off a skin lesion, there are correct ways to get that billed and paid for."
A study published in the September/October 2004 Annals of Family Medicine concludes that family medicine involves the concurrent care of multiple problems not adequately reflected in billing data. In the study -- "How Many Problems Do Family Physicians Manage at Each Encounter?" -- family physicians managed an average of 3.05 problems per encounter, noted 2.82 in the chart and recorded only 1.97 when billing.
The study's conclusion did not surprise lead author John Beasley, M.D., professor of family medicine at the University of Wisconsin School of Medicine and Public Health, Madison.
"Talk to any physician out there in the trenches," said Beasley, "and every one of them will tell you, 'Well yeah, I don't bill for everything I do.'"
Physicians don't want to take the time to look up codes, said Beasley. "The diabetes, the hypertension and the depression will get you paid, so you don't bother to bill for the other two or three things." Medicare's claim form only allows four codes per visit anyway, he added.
While accurate coding can be a challenge for busy physicians, there's another factor at play, said Robin Linker, C.P.C., C.P.C.-H., C.P.C.-P., C.H.C., president of a national consulting firm and CEO of the Rocky Mountain Healthcare Institute. Primary care physicians often undercode E/M services for fear of an audit, she said.
"Physicians feel like they're safer if they stay in the middle-level range even when they're truly providing higher levels of service," said Linker. She cautioned that the strategy sometimes backfires because undercoding can trigger an audit for potential substandard care or overutilization of a particular code.
Linker advises physicians to lean heavily on the term "correct coding." "If they code correctly and document sufficiently, the levels of service will work themselves out," she said.
Accurate coding -- whether a physician is billing Medicare or a private payer -- is essential if a physician wants to be paid for all the services provided, said Callaway. "Every day you've got an insurance company cutting your reimbursement. You cannot afford to make even the most casual errors in coding."
