Coding Detail Will Define Patients and Score Physicians

Jim Stroud, CPA
“It used to be that the doctor did the work, documented the chart, produced the CPT code, and they got paid,” says Jim Stroud, CPA, with Warren Averett Kimbrough & Marino. “That’s an oversimplification. But the point is, that’s changing now.”

Reimbursements have begun reflecting outcomes and patient satisfaction rather than procedures. “We’re moving away from ‘you had an office visit, now here’s your fee’,” says Mary Elliott, CPA, with Warren Averett Kimbrough & Marino.

To facilitate that new assessment, payers have begun requiring far more diagnosis codes to better evaluate their relevancy to the treatment and the overall health of the patient. For instance, Blue Cross Blue Shield of Alabama (BCBS) recently tripled their requested number of diagnosis codes from four to twelve. “They want to see the patient the way the doctor sees the patient,” Stroud says.

More diagnosis codes also label the patient as sicker. And sicker patients have greater value to Medicare. Stroud has had clients with numerous audit requests by Medicare Advantage Plan providers to review charts for potentially more diagnosis codes not documented in the claims.

That new detailed level of diagnosis codes also lets payers assess the accuracy and necessity of the resulting treatment codes or Current Procedural Terminology (CPT) codes. “That’s been a growing trend,” Stroud says.

But the outcomes for physicians are changing beyond simple reimbursement adjustments. “Insurance companies are now keeping scorecards on the doctor,” Elliott says. For instance, they use the negative outcome rate on tests to evaluate a physician’s diagnosis skill.

In the past, a cardiologist would use her own judgment in making referrals to the cath lab for tests to determine blockages. “But if a high percentage of those tests return negative, that proves that nothing was there which means the patient didn’t need the test,” Elliott says.

Stroud says insurance companies don’t want patients to go straight to the cath lab. They want less expensive, noninvasive procedures first. But if a cardiologist chooses the inexpensive test and it shows that 70 percent of his patients have no blockage, it proves that only 30 percent needed further treatment. “So now your medical judgment is called into question,” Stroud says.

“Payers want the treatment to cost as little as possible and the findings as near to 100 percent as possible,” Stroud says. “They want you to give the patients who need it only what they need with a limited error rate. In other words, you’ll need a crystal ball.”

“We’re moving away from episode reimbursements,” Elliott says. “We’re moving to a payment system that is going to reward on outcomes and patient satisfaction while reducing cost.”

Blue Cross of Alabama already has an electronic survey mechanism in place asking patients about their experience at a doctor’s office. The final question asks if the patient would recommend that physician to family and friends. “If the physician don’t reach a certain percent of ‘yes’, they don’t qualify for the increased reimbursement,” Elliott says.

Blue Cross also rewards physicians for participating in another program based on improving quality of care. The Patient Centered Medical Home (PCMH) model of care is designed to coordinate communication between patients and their specialists using the primary care physician as the nexus. PCMH certification, awarded by the National Committee for Quality Assurance (NCQA), runs about $1,180 every three years for two practitioners.

“The idea is to get a more efficient form of healthcare,” says Jordan Cockrell with Cockrell and Associates. She’s the first PCMH Certified Content Expert in Alabama. “The point is to cut down on the overlap of care and to involve the patient in their own care.”

At Blue Cross, physicians in the Primary Care Value-Based Payment Program (PC-VBP) can earn additional points if they’re certified as a PCMH. Those points can raise their reimbursements on various codes by up to five percent in each of three categories.

Medicare and Medicaid also grant some form of reimbursement program for PCMH in 17 states, though Alabama is not yet one of them. “These reimbursements can be anything from lump-sum payments to offset application fees and various technological expenses to pay-for-performance reimbursement,” Cockrell says.

Practices need to stay on top of these changes and options for raising reimbursements, because what they’re not doing today can impact their income even years in the future.  “2013 data will form their Medicare payment adjustment in 2015,” Elliott says. “So you could be reducing your 2015 reimbursements by one percent based on your failure to do things you need to do this year.”

“Practices need to be certain that any information from a payer is being given adequate review,” Stroud says. “It can no longer go into the top drawer of the lady whose job it is to just get today’s charges into the system.” He says staff at the highest level, including doctors, needs to ensure the practice stays sensitive to the concerns of the payers. “More and more practices are going to have to hire certified procedural coders to handle their documentation and claim submission and claims appeal processes.”


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