One aspect of coding that even seasoned coders can struggle with is communicating with physicians. Sometimes coders need to inform a physician that the information contained in his or her note lacks a detail that the coder requires to choose the correct code. Other times, coders need to tell a physician that a code that he or she has suggested be billed cannot be reported due to a rule the physician may not be aware of. These messages can be difficult to deliver, but there are some steps that we as coders can take to help the physician understand the information we are providing and in turn give us what we need to get the job done.
- Be clear and detailed about what you need from the physician. I have often seen coders send a physician an electronic message looking for additional information to be added to the report with a vague request like “Please provide a complete description of the procedure.” If we step back for a moment, though, we will realize that the physician believes that they already provided a complete description of the procedure in their original note. If we are missing a specific part of the description, it’s important to tell the physician exactly what is needed in detail.
Example: If a physician is removing a skin lesion, and he fails to document the total excised diameter of the lesion, instead of saying “Please describe the excision in detail” you could say “Please provide the total excised diameter of the lesion in centimeters,. This measurement should include the diameter across the lesion plus the smallest margin needed to remove the lesion. Thank you.”
- Remember that “coding language” and “clinical language” are not always the same. Taking the details from a physician’s report and converting those details into codes is much like translating one language into another. It’s important to understand enough of the two languages and how they are different to translate accurately and to help the physician you are speaking to understand what you need.
Example: If you are coding a debridement procedure, and the physician fails to document the deepest layer of tissue debrided, don’t say “Please provide the depth of the debridement” and leave it at that. I’ve seen many physicians answer that question with something like “3 cm” because that is physically how deep the debridement was, and they interpret the question to be looking for a numerical measurement. The problem with an answer like “3 cm” for a coder is that 3 cm could represent different tissue layers depending on the patient’s weight- there is no way for a coder to translate that information into a CPT code. To get the answer you need from a coding perspective, you have to ask the question in coding language so the physician knows what you need. For example, you might say “Please provide the depth of the debridement in terms of cutaneous, subcutaneous, fascia, muscle, or bone” which lets the physician know that “depth” from a coding perspective should be provided based on the name of the deepest layer of tissue he or she debrided rather than on a numerical measurement.
- Let the physician know why you need additional information rather than focusing solely on what you need. Physicians are very busy, and it’s easy for your request to be just one more thing in an endless list of to do’s for the day. I find that physicians generally respond in a positive way to requests for additional information when they understand why the request is important.
Example: If you are coding a nerve conduction study and realize that the indication for procedure provided is very vague and does not support medical necessity for the test per the policy for that insurance company, you could send a request for additional information before submitting the claim asking if there are any additional signs, symptoms, or diagnoses that prompted the need for a nerve conduction study. When requesting this information, also let the physician know that the indication already provided does not support medical necessity per the payer’s policy and that you are reaching out preemptively to ensure all diagnoses have been considered and avoid a potential claim denial. That explanation lets the physician know you are looking out for his or her best interest as well as that of the patient in ensuring the service is covered if there is documentation to support payment.
- If you work for a physician who performs his or her own coding and you are responsible for checking the codes for accuracy, always provide your sources when you are suggesting changes to the codes. Often times, errors in coding are just a genuine lack of understanding of a rule or guideline the physician is not familiar with. If you send a request that focuses on what you want to change without explaining what rules and guidelines necessitate that change, the request can be perceived as the physician’s opinion vs yours. When offering coding recommendations, back those recommendations up with guidelines from authoritative sources such as CMS, the AMA, or the society for that particular specialty (e.g., ACOG, AUA, AAOS, etc.).
Example: If you are coding an open splenectomy and the physician repairs a ventral hernia along the incision line for that open splenectomy, you might advise the physician of the following guideline: “Per the NCCI policy manual, chapter 6, section E.4, a hernia repaired at the site of an open incision for another abdominal procedure may not be separately reported. Therefore, I recommend coding CPT 38100 only in this case. Thank you.”
These skills of knowing how to clearly explain what you need and how to prompt responses from those who need to provide that information is as important a skill as knowing how to find the correct codes.
