Winter 2024 Issue

Physicians and Coding
By Sue Coyle, MSW
For The Record
Vol. 36 No. 1 P. 24

Ongoing education and the right tools and resources can help physicians as they face increased coding responsibilities.

Twenty-five years ago in outpatient settings, doctors dictated notes using narratives and appropriate medical jargon to describe a patient’s presenting diagnoses. Samuel L. Church, MD, MPH, CPC, CRC, CPC-I, Georgia-local medical director at Aledade, Inc, remembers that coding happened after the dictation, apart from the physician. “It kind of happened magically,” he says. “We never had to worry about [coding] then. We were concentrating on doing good medicine.”

Today, however, the landscape has shifted. Physicians are often tasked with at least some of the coding responsibilities as they input notes into EMRs. “We get to these electronic records where we are asked to provide a specific diagnosis code. Ultimately, the doctor or the provider is the one who is responsible for the code. We have to do it at the time of the note signing,” Church says.

And while the ideal may be that physicians do not take on this task or more of it moving forward—“Physicians have been required to do more coding, mainly because of work shortages exacerbated by the pandemic, but it’s definitely not the right way to go,” says Andrew Lockhart, CEO of Fathom—the reality is that they are.

When they do so without the proper training, education, and tools, costly mistakes can occur. It is important that providers have the resources they need to tackle and make the administrative responsibility of coding that falls to them more efficient and accurate.

Physician Responsibility
Many factors have led to the increase in physician coding. One is EMRs. The way in which providers complete notes and the expectations about those notes have changed in the transition from paper to digital.

“On paper, there was nothing submitted or finalized. The professional coders would translate the doctor speak into billable language,” Church says. Now, coders are still a pivotal part of the process, he notes, but doctors are expected to have the coding near final when they submit the note in the record.

This can lead to errors, particularly when physicians are overwhelmed by the increased administrative duties in concert with their clinical role. “They’re going to just click what they have to get out of the record,” says Kim Huey, MJ, CHC, CPC, CCS-P, PCS, CPCO, COC, an independent coding and reimbursement consultant in Alabama.

However, it’s not just EMRs that are driving the shift in coding responsibility. Like many health care professions, medical coders are experiencing a staffing shortage. The American Medical Association (AMA) cites studies showing a 30% shortage in medical coders. Additional surveys have found that “70% of medical practices are experiencing a shortage of coders.”

The potential lack of coders within both large and small practices means that others within the practice must take on additional administrative duties, such as physicians and coding.

“So many practices do not have someone in that practice who understands a lot of [coding]. There’s no review of those claims,” Huey says, adding that “many times now you find practices outsource their billing.”

Potential Errors
When coding is rushed or completed without the foundation of proper training, knowledge, and resources, errors can occur, causing difficulties in several aspects within the practice. “First and foremost, reimbursement,” says Leigh Poland, RHIA, CCS, CDIP, vice president of the coding service line at AGS Health. “They could be reimbursed incorrectly.”

Huey agrees, emphasizing the point. “The effect on reimbursement is devastating. You might not get the right level of service. You may not get the right code. Do that a few times a day, and there goes your revenue.”

Physicians may under- or overcode, though Huey notes that she sees undercoding more frequently. Undercoding occurs when not all services rendered or diagnoses are reflected in the selected codes. For example, a physician may provide two services but only list one or may complete a full examination but list the code as a limited exam. As a result, a provider may be reimbursed for less than they should. According to a study in ScienceDirect, “Some sources assert that individual physician practices could sacrifice as much as $100,000 annually to undercoding. From a physician standpoint, coding could also drive personal compensation since it is often used as a proxy for their clinical productivity.”

Overcoding, on the other hand, occurs when the codes submitted reflect more than the services provided and can result in overcompensation, as well as investigations and audits. “It could lead to investigations from either an insurance carrier or—a little more intense—from the OIG [Office of Inspector General],” Poland says.

According to the practice management section of the Duke Health website, overcoding most commonly occurs when a service is unbundled, meaning the different aspects of one procedure are all billed for separately, or through upcoding—when a code for a higher level of service is selected. Even when unintentional, overcoding is considered fraud.

Outside of reimbursement, errors in coding affect patients, as the mistakes can misrepresent who the patients are and what they are facing medically. “You’re going to have incomplete information that could have clinical effects. The way I like to put it is [through] this quote: ‘Every patient deserves a complete and accurate story,’” Huey says. With incomplete or incorrect coding, “We’re not telling the story. We’re not passing the clinical information on appropriately.”

She adds, with a laugh, that somewhere along the way, likely through a coding error, her insurance company came to believe that she has a diagnosis she does not. The misassigned diagnosis could influence the care another provider gives her, the treatments insurance approves, and more. While Huey has been able to clear up the mistake, this is not an uncommon occurrence and illustrates the importance of correct coding.

Church further notes that telling the story accurately for each patient through correct coding also affects the resources available. The data gleaned from medical coding allows for an analysis of where resources, time, and energy need to be better allocated and the effect that current treatments or services have had.

Burnout
The impact of physicians coding doesn’t lie solely in potential errors and their effect on reimbursement and patient information, however. Giving physicians additional administrative responsibility can also increase burnout.

“Education and training aside, the single largest factor that impacts a physician’s coding ability is burnout, which, ironically, is made worse by administrative burdens,” Lockhart says, referencing studies on the subject. For example, a 2021 study found that 58% of physicians surveyed listed “too many administrative tasks” as the top driver of burnout. “When doctors are forced to act as coders, they have to spend more time on admin each day,” Lockhart continues. “Plus, a shortage of doctors means a much higher patient-to-physician ratio, which translates to much more administrative work for doctors. This means more stress, a poor work-life balance, and less time to give patients the care they need.”

Adding to Lockhart’s point, the AMA estimated in 2022 that by 2034, there would be a shortage of between 17,800 and 48,000 primary care physicians and between 21,000 and 77,100 nonprimary care physicians. AMA president Jesse M. Ehrenfeld, MD, MPH, listed “administrative hassles that burden physicians daily and make them feel powerless to make meaningful changes,” as a primary cause for the shortage in November 2023. Ehrenfeld also identified reducing administrative burdens as one of the changes most needed to help alleviate the physician shortage.

Education
Considering the problems that can arise when coding is done incorrectly and the simple fact that physicians today are coding, one of the best ways to minimize issues and maximize efficiency is education.

At present, medical students do not have courses on coding as a part of their curriculum.

“There is just so much competition in the medical school curriculum that it [coding] rarely makes its way in. I will occasionally have a medical student who will spend a month with me for training. I do have that on occasion, but that is really a rarity,” Church says. “After medical school, you go to residency training. There’s so much to learn there. There are some specialties where there is still minimal conversation about coding.”

Church teaches workshops within a residency program to give the residents a better understanding of coding, and he’s hopeful there will be more education worked into medical programs. “I am not the only one that recognizes this as a challenge. We’re all trying to work together to find a way to integrate some sort of curriculum that is not too burdensome, complements rather than competes. We’re still working on the recipe,” he says.

Huey also provides training to residency programs and is seeing an increase in the number of programs working to incorporate coding. “I have for 15 years or more done education for residency programs. Quarterly, I will go in and do a different topic. The first-year residents, they’re not paying attention. That third year, they are all over it,” she explains.

However, in the interim, most physicians must seek training in coding once they’re already on the job (and likely have already begun coding). Such training can be overwhelming, particularly when one considers the enormity of codes that exist, the changes that occur regularly, and the training that professional medical coders undergo both before and during their careers.

“For CPT this year, we’re having over 350 different changes,” Poland says of the many updates that are upcoming. “Even as coders, we can’t just give that training once and walk away.”

Trainings should happen regularly, encompassing not just the codes but also “new industry updates,” Poland says. “What’s up and coming. What’s in the news. They also need to hear about what is OIG investigating and why.”

Poland recommends an annual symposium hosted by the AMA. “It is usually a four-day program. It’s five or six hours each day, and they have physicians on that editorial panel that address chapter by chapter the code changes. They talk through why this change was made.”

Poland also encourages practices to identify how many hours of education they can give back to their physicians for this type of learning.

Tools and Resources
Unfortunately, as aforementioned, time for physicians is often short when considering the clinical and administrative duties, and physicians will never have the opportunity for the level of training professional coders receive, not just before they enter the field but once they’re on the job as well. Thus, in addition to accessible and digestible education on coding, physicians and medical practices need to enlist available resources to help in their coding efforts. Those resources may be other people or virtual tools and platforms designed for this specific issue.

They can, for example, employ individuals and organizations to conduct audits on a monthly or quarterly basis. “Within AGS, we have several projects where the physicians do the coding. We go behind the physicians and do a sample review of their accounts and identify areas where we agree with their codes or disagree. In some projects, we might look at a larger sample or we might just grab 25 charts for the month. We look at whatever it is they’re coding,” Poland says. With the audits, physicians are able to identify common problem areas and then seek the appropriate training to address them.

Huey recommends finding ways to make the tools already in place within the practice, like the EMR, work better for the physician. For example, code descriptions can be edited to align more with the way doctors speak—something that can vary depending on specialty, geographic location, and age. Even excluding those factors, doctors are not coders and don’t use the same terminology with the same ease. Going into a platform and altering code descriptions for physicians so that they’re easier to understand and identify can help move the coding process along and lead to fewer errors. It’s a change that seems simple but can have a large impact.

Beyond that, Lockhart—who would like to see physicians doing less coding—encourages practices to incorporate coding automation. “Coding automation can help alleviate this burden,” he says. “The first and most obvious benefit is that AI [artificial intelligence] coding can take over coding work for physicians, which frees up more time for them to get some much-needed rest, spend more time with patients, and focus on more impactful tasks. Alleviating staff burnout aside, autonomous coding also significantly improves the quality and speed of the revenue cycle for practices, benefiting their financial standing.”

Utilizing such tools—whether those already in place or new tools—can help providers be more efficient and accurate in their coding responsibilities as they stand today. Moving forward, the hope is that the process continues to improve. Whether that means physicians will do more coding with increased education or additional tools and resources will be put in place to help with the coding remains to be seen. What is known is that there’s much room for change, and everyone, from the physicians to the professional coders, is ready to make those changes.

— Sue Coyle, MSW, is a freelance writer in the Philadelphia suburbs.