Lack of specificity also hampers reimbursement for professional fees, says Barb Pierce, CCS-P, ACS-EM, president of Barb Pierce Coding and Consulting Inc. of West Des Moines, Iowa. “Unfortunately,” she observes, “the code isn’t just based on decision-making, which is why physicians went to school for all those years. The guidelines [Documentation Guidelines for Evaluation and Management Services] mandate that if you forget one little bullet in history or examination, even if you’ve got the riskiest, highest-level, decision-making patient in front of you, that could pull down the whole code selection.”1
How costly might such small mistakes be for an HM group? According to the State of Hospital Medicine: 2010 Report Based on 2009 Data survey, internal-medicine hospitalists generate a median of 1.86 work relative value units (wRVUs) per encounter, and collect $45.57 per wRVU.2 If a hospitalist has 2,200 encounters per year and averages only 1.65 wRVUs per encounter, improving documentation and coding performance could add an additional 0.21 wRVUs, meeting the national average. Multiplying those 2,200 encounters by the national average of 1.86, the hospitalist could potentially add an additional 462 wRVUs for the year. Such documentation improvement—up to the national average—would equate to $21,053 in additional billed revenue without increasing the physician’s overall workload.
Dr. Pinson explains that physicians often perceive their time constraints as so severe that they’d be hard pressed to find the time to learn about documentation and coding. But he maintains that even short seminars yield “a huge amount of information that would astound [hospitalists], in terms of usefulness for their own clinical practices.”
Barriers to the Coding Mindset
Most hospitalists receive little or no training in documentation and coding during medical school or residency. The lack of education is further complicated because there are several coding sets healthcare providers must master, each with different rules governing assignment of diagnoses and levels of care (see “Coding Sets: Separate but Overlapping,” above).
Inexperience with coding guidelines can lead to mismatches. Nelly Leon-Chisen, RHIA, director of coding and classification for the American Hospital Association (AHA), gives one example: The ICD-9-CM Official Coding Guideline stipulates that coders cannot assign diagnosis codes based on lab results.3 So although it might appear intuitive to a physician that repeated blood sugars and monitoring of insulin levels indicate a patient has diabetes, the coder cannot assign the diagnosis unless it’s explicitly stated in the record.
Some physicians could simply be using outmoded terminology, such as “renal insufficiency” instead of “acute renal failure,” Dr. Pinson notes. If hospitalists learn to focus on evidence-based clinical criteria to support the codes, it leads to more effective care, he says.
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The nature of hospitalist programs might not lend itself to efficient revenue-cycle processes for their own professional billing, says Jeri Leong, RN, CPC, CPC-H, president and CEO of Honolulu-based Healthcare Coding Consultants of Hawaii. If the HM group contracts with several hospitals, the hospitalists will be together rarely as a group, “so they don’t have the luxury of sitting down together with their billers to get important feedback and coding updates,” she says.
Leong’s company identifies missed charges, for instance, when charge tags from different shifts do not get married together (Hospitalist A might round on the patient in the morning and turn in a charge tag; Hospitalist B might do a procedure in the afternoon, but the two tags do not get combined). Examples such as these, she says, “can be an issue from a compliance perspective, and can leave money on the table.”