By Mark Laperouse, MD
Strategic Advisor to Ventra Health in Emergency Medicine.
Clinicians and healthcare administrators have metaphorically been described as speaking different languages as they approach patient care delivery from two distinct vantage points.
When it comes to medical coding and billing , there’s a literal language barrier as well. The words physicians use to describe treatment steps and patient status often mean something different to the coders who translate their documentation into medical claims. A disconnect between the two can lead to down-coded claims and thousands of dollars in undercompensated care.
Here’s how this plays out: Coders rely on certain key terms and phrases in the documentation to identify appropriate coding levels and support charges billed. We may provide Level 5 treatment services, for example, but if certain phrases in the documentation support Level 4, the charges will be billed at Level 4. Using Medicare payments as an example, this would equate to 1.61 fewer RVUs and an underpayment of $53.60 for every down-coded patient. Subtleties in our descriptions effectively shoot ourselves in the foot.
Updated Evaluation and Management (E/M) guidelines rolled out by the American Medical Association in January 2023 complicated this discussion even further. The new coding guidelines place a greater emphasis on clinical judgment and decision making, which means some of the phrases we’ve used historically are now interpreted through a new lens.
If we want to be reimbursed appropriately for the services we provide, it’s up to us as physicians to cross the language barrier. Start by rethinking the way we use the following common words.
Rethink: Stable
Use: At Goal
From a medical/legal standpoint, we use “stable” descriptively to indicate a patient’s present status and readiness for further treatment. However, the concept of stability now has increased significance under the new coding guidelines, and its use in documentation could change your reimbursement.
The new guidelines shifted the focus from overall severity of the patient to specific severity of the visit, with additional consideration for whether the patient’s condition is chronic or acute. To coders, “stable” now may inadvertently indicate a less severe encounter as it relates to comorbid conditions and presenting symptoms. In this context, documenting that a patient is “stable” to transport to the ICU may ultimately undermine the medical necessity of ICU treatment.
Coders advise us to avoid using “stable” as a general descriptor. Under the new interpretation, the concept of stability should be reserved to indicate chronicity, and in those cases, we should more precisely document if a patient is “at goal” or “not at goal.”
The opposite of stable is unstable. Clinicians are hesitant to comment on comorbid conditions as “unstable” for fear of medicolegal implications. A patient presenting with chest may have a history of hypertension and diabetes. Commenting whether those comorbid conditions are “not at goal” keys the coder to the complexity of problem addressed. Avoiding comment causes them to default to “stable.”
Patient Tip: In the era of Cares Act and patient portals, a related word is becoming problematic in our communication with patients: “normal.” Patients now log in to see their own test results before we have a chance to explain them, and they are seeing out-of-range results flagged red. “Normal” will no longer make sense to them. Be prepared instead for a more nuanced discussion around medical significance.
Rethink: Observation
Use: Further Evaluation
In the coding world, “observation” is a formal status with a distinct set of CPT codes. While we often casually use “observation” to indicate that we plan to do further testing, a coder may assume we’ve formally set the patient’s status to ED observation and down-code the claim accordingly.
On the flip side, further testing and evaluation may in fact indicate greater complexity and severity of the patient encounter, which could support appropriate reimbursement at a higher level. The new E/M guidelines factor in our diagnostic processes and expertise, and a period of “further evaluation” likely includes consults with specialist, diagnoses considered and ruled out, etc. Documenting these activities more precisely will provide a detailed account the coders can use to support appropriate reimbursement.
Rethink: Comprehensive Review of Systems
Use: Medically Appropriate History
Extensive patient histories and exams are no longer required under the new guidelines. Instead of bullet counting through a comprehensive review of systems, we now use our judgment to collect medically appropriate histories and exams based on the problems presented at the visit.
Still, many of us continue to provide the exhaustive history elements and exam details we’re used to documenting. In this case, more is not better. Extra information not only wastes our time, it also buries the important documentation making it harder for coders to find. Even worse, extra details could actually undermine the coding process by providing information that inadvertently and inappropriately suggests a less-acute level of care.
Coders say it’s time to forget “comprehensive review of systems” and focus instead on conducting a “medically appropriate” history and exam.
Patient tip: During the history and exam, one important phrase can change the mood and significantly improve the patient interaction: “thank you.” Patients are scared, and they’ve usually been waiting for a while, so our reflex instinct may be to apologize for the delay. If instead we thank them for their patience, the encounter shifts from frustration to collaboration, improving patient communication and our own outlooks.
Introducing the Doc to Doc Blog Series
Ventra Health brings decades of experience both in revenue cycle management and within the clinical specialties of our clients. Dr. Mark Laperouse is pleased to bring you a thought leadership series which draws from his clinical experience as an Emergency Medicine physician and the billing and coding expertise within Ventra. Stay tuned for the next installment of the “Doc to Doc Blog” and catch up on all published posts below.
About the Author
Mark Laperouse, MD is Medical Director Emergency Services at Our Lady of the Lake Hospital in Baton Rouge, LA, and Chief Medical Officer – Emergency Medical Services at Professional Emergency Physicians of Baton Rouge. He is a Strategic Advisor to Ventra Health in Emergency Medicine.
