Janury 22, 2007

An Appealing Job
By Judy Sturgeon, CCS
For The Record
Vol. 19 No. 1 P. 4

Are you a coder? Did you ever try to explain your job to someone outside of the field? Trying to describe exactly what you do for a living can be quite a challenge.

For many years, I specialized in diagnosis-related group (DRG) coding for hospital inpatients. Sometimes I’d try to summarize what that entails, until I noticed that 98% of the audience had glazed eyeballs after the first couple of sentences. Then I started having more fun with the definitions. My favorites included, “I read cool medical stuff all day long, and they pay me.” Too many people gave me their resumes, though.

“I translate medical language into numerical language, so we can bill you for a lot of money.” That’s good to get people to quit telling you about their surgeries. Don’t give them your address or phone number, though, in case they actually get a hospital bill in the immediate future.

“I work for the government translating your medical information into a secret language for state and federal research and study.” This makes people back away from you slowly, with no desire for your address or phone number. They also go home and change their phone numbers to unlisted.

Entertainment value aside, you can’t begin to describe what coders do for a living in one or two sentences. Some simply check off on predescribed codes and terminology while others are federal compliance experts, consultant auditors, and international data gurus.

Amid these various career opportunities, a growing need for coders who can handle payment appeals has emerged. When the denial is based on the codes themselves, having someone involved who knows the relationship between documentation and code system and denial issue can be priceless. Literally, you can’t put a price on this skill—it is worth huge amounts of the provider’s money to have a code-savvy appeal coordinator at the helm in denial management.

How many facilities and medical practices have taken advantage of this fact? My guess is that facilities first focus on having enough coders to handle regular coding then they may look into having extras who can pick up payment appeals. If you examine the issues, however, you may reconsider your appeal staff recruitment efforts to include those with coding credentials.

Admissions can be denied due to a nonspecific principal diagnosis, as providers of Medicare services are finding out this fiscal year. If a myocardial infarction or breast cancer is not described as to site or type, your claim may not even be accepted.

The coder is the right person to scour the available documentation and see whether there is some obscure physician comment somewhere in the encounter to enable a more specific code assignment for the diagnosis. If there are none in the current documentation, the coder can best approach the attending physicians to educate them regarding the Medicare denial issue, get the documentation to better specify the code at hand, and—one would hope—prevent the issue from recurring with their patients in the future.

Even when the entire claim is not completely denied, codes can still affect which payments are made or denied. Outpatient claims are certainly not exempt from denials on coding issues. While the individual dollar value of each line-item denial may not seem significant at first, the volume of denials can create a significant financial burden.

How many times does the provider bill the injection but not the drug—or the drug but not the injection? How many times does the provider bill for a disease-specific medication but does not include a code for the disease that will get that drug payment approved? These cases in particular can be high in volume and cost. Once again, coders with a comprehensive knowledge of the medical staff, the codes, and the payment rules can be worth their weight in gold.

Providers struggling with payments from managed care payers have their own issues with code-related appeals. When a physician’s office contacts the managed care group to authorize a procedure, how often does the authorized procedure code match the procedure performed? Even when a coder does not personally handle the appeal process, it is critical to include one in the appeal communication. The surgeon may be willing to describe why the procedure was modified from the original intent, but the coder will be able to validate the resulting code changes for a retroactive authorization and/or payment correction.

Facility nursing staff trained in utilization review are critical for front-end authorizations for both admission and length of stay; however, many are not experienced coders. They may get authorization for a DRG based on the presenting symptoms at admission, such as chest pain. The final diagnosis and DRG will be based on the probable cause of the pain, and DRGs can be as varied as those causes.

Three patients approved for chest pain admissions may all be paid at DRG 143 even though the claims will bill one for a congestive heart failure DRG, another for a reflux DRG, and the third for a muscle strain DRG. If coders work with the utilization review staff, it can help prevent a DRG mispayment. Utilize coders with the appeals staff, and they may be able to work with the payer to correct the DRG via the documentation and the appeal process.

Clouding the issue is the fact that third-party DRG payers may not even employ coders. If they don’t have professionals who understand coding—much less DRG assignment—obtaining the correct payment can become a financial nightmare. Correct codes may be deleted and the DRG downcoded by the payer for not having enough treatment for the coded diagnoses. They may delete codes for secondary conditions that affect patient care because admission criteria were not met. They can refuse to validate possible and probable diagnoses on inpatient cases and instead pay the DRG for the chief complaint.

They could even assign DRGs just because they sound right for the individual case. Imagine trying to teach an entire corporation how to code after they’ve already taken on a huge DRG contract—learning to do it right will cost them dearly.

Are you a coder who, having grown tired of cranking out endless charts, is looking for a new challenge? Are you a physician or facility billing manager searching for more effective methods to corral the correct payment for the services that have been provided? Think about coders as denial management and appeal coordinators—you just might be each other’s new best friend.

— Judy Sturgeon, CCS, is the hospital coding senior manager at The University of Texas Medical Branch in Galveston and a contributing editor at For The Record. While her initial education was in medical technology, she has been in hospital coding and appeal management for the past 18 years.