As a residency curriculum committee we periodically review anonymous feedback from our residents about their learning experience. This is an invaluable process that brings important perspective to those of us who can lead improvements. In many cases, the improvements benefit not just residents, but faculty and patients too. An example that recently highlighted this is our inconsistent coding of outpatient visits.
Many residents struggle with inconsistency in how faculty are instructing them to code outpatient visits. Unfortunately it is true that the advice we give often differs. This makes it tough for residents as they are working to learn clinical medicine, and at the same time find themselves trying to memorize each attending’s unique coding processes, as opposed to one correct practice. This can lead to frustration and inefficiency. At the same time it is understandable and almost unavoidable that this happens – we work within an absurdly complex coding system. Our group works hard to help faculty be on the same page with coding practices. Much valuable time is spent teaching coding, and updating latest processes and recommendations for coding. This is uniquely challenging because of the pace of change in this complex system. What is the latest interpretation regarding which patients residents need to have their attending personally interview and examine while they are in clinic? How does this differ based on which department runs the clinic the resident is working in that day? What is that new code for transitions of care? How many data points are required for a 99214? And even if you have all those data points but not enough diagnoses, or the diagnoses are not new problems, then can you still bill a 99214?
While we can’t change this complex coding system, and while it is hard to get us all on the same page in such a complex system, we can increase our use of one great resource: our coding pool. While helping us migrate toward accurate and consistent coding practices, coders can also resolve our differences of opinion as they arise.
Did you know that the University of Utah Health system has a pool of coders dedicated to supporting outpatient primary care providers in this effort? There are extremely knowledgeable, easy to forward charts to, and responsive. I have been sending them any chart I have a question about, or just want to feel more confidence about. I forward 2-3 charts most weeks. Several months ago, when I started to do this, the coders were repeatedly telling me I under-coded. Sometimes the explanations were confusing, so I asked for clarification and next steps. They would usually fix the error for me if the bill just needed to be resubmitted. If documentation is an issue, they will explain why and tell me what I need to do. For a few months now they are mostly confirming for me that I am on the right track.
I feel less frustrated than I used to because my confidence has improved. If I have a question, I know what to do and that it will be resolved correctly and easily. I have more confidence that what I am teaching our residents is not just my opinion, but rather the best available information on correct billing. An analogy could be made to evidence based medicine. If something doesn’t pan out in the examination of the evidence, why are we spending our time teaching it, or our learner’s time learning it? We can apply the same standard to coding. Let’s not spend time teaching or learning coding practices that are not consistent with what our coders recommend.
So an invitation for anyone who struggles with coding, teaches residents, or sees an inconsistency in what you are being taught: Do you have a pool of coders available to you? If so, use them. Set a goal of forwarding them at least once chart per session. After a few charts, you won’t even have to hold yourself accountable to that goal – you will wonder how you ever got by without these essential members of our team.
Susan Cochella, MD, MPH is a Clinical Professor in the Department of Family and Preventive Medicine at the University of Utah School of Medicine.