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Best Practices: Why Your Practice Needs a Master Coder

Medical practices are faced with a number of changes each year, some of them unexpected. But one change that comes each year are the changes in the annual revision of current procedure terminology (CPT) codes.  In 2011 there are 212 new codes, 106 revisions and 110 deleted CPT codes.  Are you ready?  If not, there's a chance your payments will be stalled and some services may go unpaid if you don't apply these changes.

It's important for every practice to examine CPT coding modifications each year and revise those that affect their specialty and the services they offer. The updated codes must be changed in the billing system's charge master and on the encounter form. One of the best ways to make sure this happens is to assign one person in the practice to be the coding expert and hold him or her accountable for implementing these changes.

The Master Coder (MC) may be a new concept for some practices, but embracing this can ensure the practice is compliant. Here are some tips on how to succeed with executing the role of an MC in your practice so that you get paid accurately and timely for what you do.

First, define the role.  This means determining responsibilities the MC will assume.  Typically this includes:

1. Monitor coding application, ensuring it accurately represents the services performed and services are coded appropriately to get you paid correctly.
2. Required to monitor coding and billing performance.
3. Expected to obtain updated CPT and HCPX procedural coding books each year and ICD-9/ICD-10 (diagnostic coding) and implement changes.
4. Required to attend formal coding continuing education courses each year with close attention paid to changes affecting your specialty.  
5. Expected to provide entire staff with an annual coding update based on changes that emerge each year.
6. Responsible for conducting formal coding training sessions for new providers and new billing staff members within 30 days of hire.

Next, identify the person on staff best suited for this position and discuss the role with him or her.  Clarify the responsibilities and accountabilities, and what education and support will be provided.  To begin with, don't assume the person you have in mind is an expert.  If he is not a certified coder get him trained and certified. The AAPC coding certification is acquired through gaining expertise and passing the test provided by the American Academy of Professional Coders (www.aapc.com). Certified coders are required to obtain continuing education credits to maintain their certification.  You will receive the benefits of providing this training for your MC. She will be the one who keeps the entire practice on course with coding properly.

The MC should also monitor coding performance and variances between providers each month and graph them, presenting the reports to the management team with any explanation she may have to explain variances.  In other words is there a reasonable explanation why Dr. Able is providing more low level E & M services, and Dr. Code is coding all level 4 and 5 CPT codes? It may be reasonable if Dr. Able sees patients with minor problems and Dr. Code sees more patients with multiple chronic problems.

What about those ICD-9 diagnostic codes being used for those chronic visits? Do they support the medical necessity for the level of service?  If not, you might be getting claims rejected or down-coded. On the other hand, if a number of discrepancies are seen, it may be time for a coding audit to clarify the validity of the variance and determine if additional provider training in either coding or documentation of services is needed.

ICD-10 implementation is slated for October 2013. APC is already offering training on this complex code-set that will require far more specificity in diagnostic coding.   This is reason enough for medical practices to create the role of Master Coder now, so you have a skilled expert on board before ICD-10 takes effect.

Finally, use available resources to stay updated. There are many sources to keep your MC in tune with coding updates and billing regulations, including seminars, webinars, podcasts and  other on-line sources that can provide needed support on coding matters such as www.findacode.com.  This subscription service can save you time and pinpoint coding changes that are relevant to the practice.  Another source is www.codapedia.com, which is a free service that offers an open dialogue for coders to share information and offer tips on coding application.

 Coding, documentation and billing is the lifeline of the revenue flow for the practice. With physicians typically charging at least $500,000 a year (and double that for some specialties) it's worth protecting the revenue.  There's a big upside to having a MC that knows her stuff and helps the entire office understand coding requirements so that you get paid what you deserve!

About the Author

Judy Capko is the founder of Capko & Company and author of the popular book "Secrets of the Best-Run Practices," Greenbranch Publishing, September 2005. Judy has specialized in medical practice operations and marketing for more than 20 years, and is a certified risk management specialist.

Trusted by thousands of doctors, Kareo is the web-based practice management and medical billing software with integrated electronic claims processing that's the most user-friendly, easy-to-buy, and easy-to-set-up solution on the market (http://www.kareo.com/). 

Current Procedural Coding Expert 2011, 1st Edition $94.95 Turn to the resource that goes beyond basic coding with the Ingenix CURRENT PROCEDURAL CODING EXPERT, your CPT® coding resource. Equipped with the entire CPT® code set this easy-to-navigate resource arranges codes in a design known to speed coding, billing, and reimbursement. You'll also find a comprehensive listing of annual code additions/changes/deletions/reinstatements in the appendix, new code icons and notes, plus reimbursement information and mid-year changes not found in the American Medical Association's (AMA) CPT® code books.

Step-by-Step Medical Coding 2011 Edition, 1e $23.51 Take your first step toward a successful career in medical coding with comprehensive coverage from the most trusted source in the field! Step-by-Step Medical Coding is the practical, easy-to-use resource that shows you exactly how to code using all of today's coding systems, providing an in-depth introduction to essential coding concepts followed by practice exercises that reinforce your understanding. In addition to coverage of reimbursement, ICD-9-CM, CPT, HCPCS, and inpatient coding, the 2011 edition now provides full coverage of the ICD-10-CM diagnosis coding system in preparation for the transition in 2013. No other text on the market so thoroughly prepares you for all coding systems in one source! Carol J. Buck's proven step-by-step approach guides you through difficult concepts in the most direct, straightforward manner to ensure complete understanding. Dual coding prepares you for the switch to ICD-10. In Units 3-5, for every exercise and chapter review question with an ICD-9 answer, you are provided with the matching ICD-10 code. In-text exercises throughout each chapter reinforce coding rules and concepts and follow the book's step-by-step approach. Quick Check features immediately reinforce key concepts and test your retention and understanding. Toolbox features provide additional real world cases for analysis and applying knowledge to specific case elements. Concrete "real-life" coding examples allow you to apply important coding principles and practices to actual scenarios from the field. Full-color design with over 450 illustrations ensures easy navigation and presents material in a unique, compelling way. Coding Shots provide tips for complicated coding scenarios and advice for entering the job market. From the Trenches quotes provide valuable, up-to-date insights from instructors and professionals in the medical coding field. Stop! notes offer a brief summary of material just covered to help ensure retention and understanding and provide a transition into the next topic. Caution! notes warn of common coding mistakes and reinforce the concept of coding as an exact science. Check This Out! boxes offer notes on accessing reference information, primarily via the Internet. Official Guidelines for Coding and Reporting boxes in Units 2 and 5 present the official outpatient and inpatient guidelines alongside text discussions. Coder's Index makes it easy to instantly locate specific codes. Practice activities and Coding Guidelines are available on the companion Evolve Resources website to help reinforce key concepts from the text and provide fast, easy access to the most up-to-date content.A free 30-day demo of SpeedECoder lets you complete cases using an actual online encoder.Updated content reflects the latest coding developments so you can practice with the most current information available. New ICD-10-CM chapters prepare you for the upcoming 2013 transition.ICD-10-CM Official Guidelines for Coding and Reporting...

Current Procedural Coding Expert 2011, Compact, 1st Edition $85.45 Turn to the resource that goes beyond basic coding with the Ingenix CURRENT PROCEDURAL CODING EXPERT, your CPT® coding resource. Equipped with the entire CPT® code set, this easy-to-navigate resource arranges codes in a design known to speed coding, billing, and the reimbursement process. Also included is clarification on the annual code changes and their implications, plus reimbursement information and mid-year changes not found in the American Medical Association's (AMA) CPT® code books.

2011 ICD-9-CM Coding Pocket Guide $46.95 The 2011 Pediatric ICD-9-CM Coding Pocket Guide is designed as a quick reference for pediatric diagnosis coding in a covenient pocket-size format. Streamline pediatric diagnosis coding with this newly revised spiral-bound quick reference. Here are basic guidelines for selecting appropriate International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes for commonly encountered pediatric diagnoses and diseases. All 2011 ICD-9-CM codes are indexed by diagnosis and organized alphabetically for easy identification. Also included is a glossary of key medical abbreviations. Formatted as a handy spiral-bound book, it slips right into your laboratory coat pocket and is always available for ready access.

2011 Coding Workbook for the Physician's Office, 1st Edition $52.99 2011 CODING WORKBOOK FOR THE PHYSICIAN'S OFFICE contains coding exercises that reference sections of the CPT and ICD-9-CM coding manuals as well as exercises require HCPCS Level II codes. Condition and procedure statements in the exercises reflect the current annual editions of the coding manuals. By completing the exercises in this workbook, you will expand your medical vocabulary, improve your coding skills for the physician's office, and learn to code only what the documentation supports. 2011 CODING WORKBOOK FOR THE PHYSICIAN'S OFFICE also covers The Center for Medicare and Medicaid Services (CMS) guidelines for diagnosis coding and reporting by physicians and this new edition includes an additional chapter called, "Moving from ICD-9-CM to ICD-10" to help prepare you for the upcoming shift to ICD-10-CM. Additional practice with ICD-10-CM is included within the ICD-9-CM section. You need current CPT, ICD-9-CM, and HCPCS coding manuals to complete the exercises in this workbook.

Workbook for Step-by-Step Medical Coding 2011 Edition, 1e $17.95 Strengthen your ability to code accurately and obtain the correct reimbursement for medical services with this helpful workbook. Specifically designed to parallel the content of Carol J. Buck's Step-By-Step Medical Coding 2011 Edition, it provides more than 1,000 questions and terminology exercises (with odd numbered answers provided), as well as over 90 original source documents to familiarize you with the materials you'll encounter in practice. This edition now includes questions covering the ICD-10-CM diagnosis coding system.More than 1,000 questions and terminology exercises follow the same answer format as the main text to improve your coding and critical thinking skills (with odd numbered answers provided). Chapters 1-30 contain three types of activities/exercises: theory (fill-in-the-blank, multiple choice, and true or false questions), practical (line coding exercises), and reports (coding from original source documents) to help you evaluate your understanding and ability to apply concepts to real-world situations. Chapter 31 also includes exercises on principle diagnosis and sequencing to help prepare you for inpatient coding challenges. Chapters 13-31 feature ICD-10 dual coding where every workbook question with an ICD-9 answer is provided with the matching ICD-10 code. Original reports, cleared of all confidential information, simulate real-world experience in such areas as: Arthroscopy Fracture repair with skeletal fixation Muscle repair Bronchoscopy Adenotonsillectomy Thoracentesis Endarterectomy Cesarean delivery Tubal ligation Amniocentesis Laboratory PathologyUpdated content reflects the latest coding developments so you can practice with the most current information available.New ICD-10-CM chapters prepare you for the upcoming 2013 transition with plenty of theory, practical, and reports questions covering the ICD-10-CM diagnosis coding system.

Next Step, Advanced Medical Coding 2011 Edition $54.77 No Synopsis Available

Workbook for Step-by-Step Medical Coding 2011 Edition $23.34 No Synopsis Available

Medical Coding Online for Step-by-Step Medical Coding 2012 (Hardcover) $275.91 This money-saving package includes Medical Coding Online for Step-by-Step Medical Coding 2012 Edition (User Guide and Access Code), Step-by-Step Medical Coding 2012 Edition Textbook and Workbook.

Medical Coding (Paperback) $156.93 Designed for the beginning student, this easy-to-ready medical coding book offers comprehensive coverage of current and upcoming codes. Highlighting ICD-10-CM, ICD-10-PCS, and ICD-9-CM ( vol. 1,2, and 3), MEDICAL CODING: A JOURNEY teaches code sets that healthcare providers and insurances use, while addressing medical terms, medical specialties, medical records and healthcare issues. Examples, photos, and guidelines walk students through each step of the coding process and explain common medical procedures and diagnoses. Unique exercises use video, chart audits, online research, and medical record interpretation to reinforce coding skill and accuracy.

Medical Coding Online 2011 for Step-by-Step Medical Coding 2011 Edition (User Guide and Access Code) $38.47 No Synopsis Available

Medical Coding Online 2011 for Step-by-Step Medical Coding 2011 Edition (User Guide, Access Code and Textbook Package) $107.2 No Synopsis Available

Understanding Medical Coding (Paperback) $238.12 With coverage of both inpatient and outpatient coding, Understanding Medical Coding: A Comprehensive Guide, Third Edition teaches students everything they need to know about medical coding. Through clear, step-by-step instructions, students are taught how to code a claim correctly, link the correct CPT and ICD-9-CM codes for reimbursement, understand adjustments as well as how and when to bill patients, and determine what to do if there is a denial or rejection. Coverage has been thoroughly updated to include information on ICD-10-CM and how it compares to ICD-9-CM. CPT coding and modifiers are also discussed, as well as more code-specific information, concentrating on specialty coding and the levels of coding. Additional case studies, practice exercises, tips, examples, tables, charts, and photos have been added in order to improve student performance and ensure that they are well prepared for a medical coding position in a variety of settings.

Medical Coding Fundamentals (Paperback) $163.53 Medical Coding Fundamentals provides a fresh approach to medical coding that reflects the way real medical coders succeed in their jobs. An introductory chapter refreshes students on the basics of A&P and medical terminology. Authentic examples clearly illustrate key areas, from the basics of CPT, ICD and HCPCS through complex topics such as modifiers and E/M. In order to train students to become proficient, accurate coders who are well-prepared to take the steps towards coding certification, exercises throughout each chapter and the entire final chapter provide plenty of coding practice, as well as critical thinking to prepare the next generation of coders. Don`t worry about ICD-10, either. Medical Coding Fundamentals tackles the transition head on, providing you with just the right blend of coverage.

Ethics in Medical Coding (Paperback) $182.36 Ethics in Medical Coding: Theory and Practice addresses the challenging topics of ethics and compliance in medical coding, billing, and health information management. From choosing a diagnosis or procedure code to navigating payer requirements and installing an EHR system, this text`s down-to-earth style explains potential ethical dilemmas and offers practical methods for solving them. Case studies and exercises throughout each chapter provide opportunities to go beyond the theory. Chapters on compliance programs, health care reform, EHR, and ICD-10 ensure that you`ll be prepared to navigate the ethical challenges ahead.