How Medical Coding Training Could Help

Categories: Billing, CHC, PMG Insights Blog

June 12, 2015

Cutting Healthcare CostsCHC providers are notoriously bad at coding. Don’t believe me. Look at the data. CMS limited payment of multiple encounter rate payments at CHCs on a single date of service because… wait for it… less than .5% (that’s right, half of one percent) of all claims submitted to CMS indicated a CHC patient sees more than one core provider on a single date of service. So all that talk about “integrated health” modeling (for which CHCs should receive kudos and credit) seems incredibly unsubstantiated. In other words, CHC patients may regularly see a combination of primary care, behavioral health, and other social service professionals on a single date of service but no one can demonstrate it happens.

Hear’s a more recent, albeit anecdotal, example. We visited in early May, a CHC in Massachusetts; i.e., a state which is chest deep in Romney Care… which was the precursor to the Affordable Care Act (a.k.a ACA and Obama Care). All doctors, NPs, PAs, etc. (think CHC core providers) in the state receive a risk score based on the “complexity” of patients seen. The larger group practices (think entire CHC) receive an aggregate or corporate average based on how their employed providers perform. How is this “risk score” calculated? You guessed it. Coding.

CHCs with Complex Patient Demographics

So this Massachusetts’ CHC has a complex patient mix of indigent, multilingual, recently emigrated, under-educated, socially marginalized, and generally challenged adults and kids. Integrated care intertwining medical, behavioral health, dental, and other outreach services are the norm for most patients. This CHC’s demographic mix and clinical care setting are commonplace in nearly all of our CHC clients across the 50 United States and territories. In Massachusetts, the risk score mean of 1.0 is the “norm” by which all practices are evaluated. Not overly complex or overly simple, the 1.0 translates to just average. What, therefore, is a fitting score for a CHC? What I’m asking is what percent above the norm makes sense or seems justified.

While there exists no correct answer, the CHC’s medical director said they’d expect to see a score of 1.2 to 1.3. Stated otherwise, their data should demonstrate a CHC’s patients are 20% to 30% more complex than those seen elsewhere in ALL settings including private practices in affluent suburbs. After sharing this perspective he offered that his CHC’s score was astonishingly low at .85%; i.e., 15% less complex than the “norm.” Holy Toledo, Batman. Talk about “under performing” or at least under emphasizing the complexity of the patients seen at this CHC… a CHC with a sizable HIV, substance abuse, and behavioral health population.

How could this happen? Well, in short their HCPCS (e.g., CPT) and ICD coding is substandard… and that is a generous way of putting it. They do (have done) a less than adequate (OK, miserable) job of demonstrating complexity of the patients they see. In other words they don’t clearly capture (submit) coding data to demonstrate their oversight of their common, every-day, run-of-the-mill patients with multiple co-morbidities, socio-economic challenges, and substandard education making compliance with health care protocols difficult if not impossible. Here’s a quick example from this CHC.

A 40 year old female, bi-lateral lower extremity amputee patient with pulmonary, cardiac, and a couple of other chronic issues dropped from a risk score greater than 1.6 to just below 1.2. Why? How? After checking coding history, it was determined that the bilateral amputee status had not been submitted via ICD to the third party payer in the past calendar year. The result: the payer presumed the complexity had diminished. Not to be crass, and repeating what the medical director said to his team during our work that day, but it’s “not like the patient regrew legs.” However, if the providers don’t (through optimal coding) consistently and thoroughly report the commonplace complexity, payers don’t see it.

For this CHC, such low scores means they receive a disproportionate (think lower) share of withheld (risk adjusted) revenue paid to providers who demonstrate through coding that their patients are more complex. The money goes not to those with actual patient “hardship” but to those who are better at submitting coding data that makes then look that manage more “hardship.” Fair? No. Equitable? Not close. Coming to a market near you? You betcha.

CMS has a congressional mandate to transition 50% of all Medicare compensation to “risk adjusted” vs. historical, straight for-fee-service. Massachusetts (like Oregon, Washington, California, and others) seem to be leading this charge but all states are following. Remember the CMS acronym is the Centers for Medicare and Medicaid Services (an aside but it should really be names CM2S). Anyway, we tend to think they are just Medicare. Further, Medicare policy sets the groundwork for expectations and policy around other payers’ market trends.

Riddle yourself this one: Do you really think your elevated Medicaid PPS rate will remain permanently intact in today’s fiscally challenged economic environment? If you do, explain away Medicare’s CHC transition from cost based encounter rate to PPS (CR 7038 in January 2011) or why hospitals won’t ever again be paid for Medicare readmission occurring withing 30 days of discharge. Watch as the commercial and Medicaid programs follow. These two examples are just early “shots across the bow.” More are coming and your CHC had better be ready.

Simple put, if your CHC does not through optimal coding (i.e., HCPCS (e.g., CPT) and ICD (a.k.a. diagnosis or symptom)) demonstrate the real clinical challenges experienced each day by your providers, expect less money in the coming months or years. It’s no longer “if” but rather “when” this change hits. This raises a mission critical question: How do you improve coding performance at your CHC? Several thoughts follow below.

Training and Education

Your providers can learn coding. CHC coding is not necessarily complex and if providers can get through medical school coursework and exams, learning coding is doable. The real challenge is motivation, or lack there of. Incentive based compensation has not demonstrated sustained improvements in coding. Further, most CHCs don’t have the financial wherewithal, tactical capability, and/or desire to elevate compensation to providers just to improve coding. However, we have witnessed sustained improvement when CEO, CFO and Medical Director leadership are in lock-step around expectation and perceived importance of coding. Talking about it once a year vs. making optimal/ accurate coding part of weekly or bi-weekly clinical meetings (and staff compensation) send very different messages. The latter tends to effect real change.

In-house Coding Professionals

Of late, especially since ICD-10 has become more of a reality, we are asked whether CHCs should hire certified coders. With ICD-10, and if you have the financial solvency to manage such, we recommend it. However, consider several pragmatic challenges. First, like board certified doctors, not all certified coders are equal. Some are great and others, barely competent. Even if initial evaluation of your new coder’s work product looks good, how do you evaluate coding performance? You can hire an outside firm to audit a fixed percentage of your coder’s work product and this may improve your comfort level, In fact, let’s assume you hire an outside firm to audit/ educate the coder and make certain your coder remains well-educated via CEUs and ongoing coursework. A bigger quandary remains. How do you retain a top tier certified coder when his/ her skills (if s/he is a solid coding professional) are for big money being sought by other for-profit practices and/or consulting firms with deeper pockets? This doesn’t begin to address how you evaluate his/her productivity, assure internal redundancy of skills, ongoing provider education in response to findings, etc. In short, in ain’t as easy as just hiring a certified coder.

Partner with CHC Coding Experts

Simply stated, your CHC cannot be great at everything. Focus on what you do best; i.e., maximizing access and quality care to your community of patients who seek and need such. Partner with a third party firm who works all day long to be the greatest in the world at CHC coding, billing, and reimbursement. Frankly, that’s been PMG’s “hedge-hog concept” (Good to Great by James C. (Jim) Collins. Good to Great: Why Some Companies Make the Leap… and Others Don’t. Harper Business: 2001.) since 2006. By hiring an outside firm you avert the need for internal coding redundancy, potential mismanagement, knowledge hoarding (held hostage) by one employee, singular liability around inaccurate/ abusive coding, etc. And, do you have liability insurance to cover you in the event a coding error results in third party payer liability of penalty? Hiring an outside firm mitigates liabilities and headaches. It cannot hurt to get a quote and see what your options look like.

Whether you elect to hire your own certified coder or partner with an outside firm, one cannot argue the financial benefits. Ask your providers this question: If you did not have ti do any coding, could you see one more patient each day? We’ve been asking and the answer is always yes, at least one more patient seen each day. The national UDS average payment per CHC visit is $114. At four patients per week ($456 weekly) times 48 weeks of work, your CHC makes an additional $21,888 per provider per year. The average CHC has 10 FTE providers making this elevated revenue number well over $200,000. AND your coding data improves. Seem like a no-brainer.

Listen, some of you may not see any change in compensation today. However, change is coming and certain CHCs won’t survive. Decisions made today (including lack of action) will be evaluated down the road with 20-20 hindsight. What will your successors and future board members say about your performance, today? Will they look back and praise a froward thinking, early adopter leading his. her CHC to a path of fiscal prosperity or wonder why compensation woes continue to plague you CHC’s ability to expand patient access to affordable healthcare? Lead the way to optimal performance. Or, prepare to justify being the laggard. Your choice.