All right, guys, so we're going to talk, these, the next two talks that I have are kind of go together. The first thing that I'm going to talk about is leading and teaching a coding team. And then we're going to go, that's going to segue into my next talk, which is auditing physicians and providers within your practice. So the first one pretty well is going to be short and sweet as far as leading and teaching a coding team. So let me see if I can get, there we go, all right. So a couple things you want to look at, you know, first of all, who's going to make the right fit? Just, I'm going to just say this, just because someone is a certified coder doesn't necessarily mean they're going to be the best fit for your practice. You want to look at what kind of education that they've had and where have they had it. And then the training that they've received. You also want to, and I think this is probably going to be the most important is you want to look at work experience. You know, again, you could hire a coder that just went through a coding exam workbook and then took the test and passed it. You know, there are a lot of people out there that are good test takers. I, for one, am not a good test taker. And when I passed all my certifications, I was floored to be honest with you. What made me, to me, what made me a great coder auditor is working with providers and doing coding for that specialty. That I think is going to be the best thing. You're also going to look at productivity and accuracy. You know, again, you don't want to hire someone that's going to be on TikTok on their phone for six hours a day. You want to make sure that they're productive, but you also want to make sure what they're doing is accurate. So how often should this be measured? What kind of percentage should you look at? And productivity standards, how many charts should be audited per hour? And you can Google this information and you will find several different answers, okay? So I just, I'm giving you the best guess recommendations at this point. So we'll get into that. And then we're going to talk about a compliance plan for your practice, okay? So you can have coders, billers, physicians all day long, but if you don't implement it and implement a compliance plan and make sure that everybody follows it and keeps it up to date, then you might have some issues, okay? And I think the big thing is communication is key. It's critical to your practice. Compliance officers, coding managers should effectively communicate policy changes. Coders should have open door communication with their providers. Providers should understand the important role of their coders. And I know sometimes, you know, Kathy and I go into a lot of different practices and we do training and everything. And we have practices that we work with that the physician and the coder like work together every day. They're a great team. They're always communicating with one another. And then we go into practices where, oh, yeah, Sally, you've worked here for two years. This is the first time I'm meeting you. How's it going? And that's the first time they've ever seen each other. We've got, there are organizations where all the coders work from home. You've got some, though, that have the coders right there in the same office as your providers. So there's all these different dynamics and that kind of, that right there kind of determines to the communication styles and, again, the feedback and whatnot. So we'll get into that. So hiring that best fit coder, you can look to see if they have a certification. You definitely want to try and hire a coder that is certified, OK? That pulls more weight when you're trying to, you know, defend claims, defend, you know, what you build, modifiers, things like that, if payers are kind of looking and seeing what you're doing. So, yes, having a certified coder is great. There are many, many, many, many, many different certifications that are out there. The top four, I guess, is where I, what I see come across specific to GI practices. Obviously, CPC. That is your certified professional coder. That is through the AAPC. It's American Academy of Professional Coders. You will see some of these as CPC-A, and what that means is they're newly certified. They're kind of in an apprentice program. So after they get a certain amount of years under their belt or a year under their belt, that A will drop off. Then you've got CGIC, OK, Certified Gastroenterology Coder. This is also through AAPC. So a lot of coders will get their CPC, and then they'll get a subspecialty. Sometimes you just see coders that have just the specialty, and that's OK. So CGIC is good, again, through American Academy of Professional Coders. We also have CCS, Certified Coding Specialist. Now that's going to be through a different organization, which is AHIMA, American Health Information Management Association. OK, typically when I come across AHIMA certified coders, they're in a hospital setting. They have more hospital coding background, which is a little bit different than professional coding, but still great certification. And then you've got the QMGC, which is Qualified Medical Gastroenterology Coder, through QPRO, which is Qualified Professionals, all right. So any of those work, but again, it really means I took a test, I learned the overall guidelines, and I passed the test. It is a great test. You know, you have to get a certain percentage. You have to pass each section. They're very, very hard, difficult tests. But I think, you know, what else do you need to have that best fit coder? And it's work experience, OK. Best practice is to hire a certified coder, but if they have GI coding experience, that is a plus. Number one, it's hard to come across certified coders. But number two, it's really, really hard to come across a certified coder that has a bunch of GI coding experience. So if you can find both, grab that staff member, grab it, hire them. If you find a coder that isn't certified but has GI coding experience, they can be given a time frame to complete and pass a coding certification. And there's a lot of practices and hospitals that do that. You know, they'll hire you based on your experience, and they'll say, OK, but we require our coders to be certified. So you have till this point, and a lot of them will pay for their certification as well. They'll pay for their study guides, their certification, et cetera. So again, if you can find someone that has both, great. If not, find the one that has experience, and then they can work on that certification. Also another best fit, hire a coder that has experience with provider education and feedback. I can't stress that enough. You know, you can, and there are coders where they go to work, they code, and they leave, and that's fine. And the only real feedback is tasks and emails. Well, sometimes that becomes a little bit cumbersome, not only for the provider, because they have to fix everything, but for the coder as well, because they have to hold that, they can't bill it out, things like that. And so it delays the process. But if there's like open communication, it goes smoother. And again, you know, when I first started doing this, I'll be honest with you, I was like, I am not talking to the doctor. They're going to yell at me, and they're going to scare me away, and I'm never going to do this again. Well, then I kind of had to stop doing that. And I came from a university setting where they are teachers. They do this all the time, they teach, but they teach obviously patient care, and procedures and things like that. But they, they had a good communication flow, because they were just used to teaching. So it wasn't really much of a burden. All right, well, then that got me to be confident in feedback, okay? Because you can't just, you can't just go to a provider and say, this is not a level four and not explain it. Okay, you have to have, we kind of refer to it as book chapter verse, we have to cite our sources, we have to know what we're talking about, we have to be confident in what we're talking about. But we also have to be team players, okay? So if I find out that Medicare is no longer accepting this modifier, or that diagnosis code, I'm not going to just keep that information under my, under my breath in my desk and not share it with everybody, okay? Everybody should be aware of it. Coding managers, billing managers, compliance, compliance directors, anybody that finds out good useful information and things that have to, you know, make us change the way we're billing things has to be communicated with everybody. And again, it's really good, you know, I don't ever want to inundate a provider with a bunch of paperwork or a bunch of stuff, say, hey, here, here, read this CPT book and learn yourself. You point out the bullet points, the main points, because at the end of the day, we don't have time to read books and whatnot about coding and billing 101, all right? But again, the important things have to be communicated, so you have to have a good coder that is a good communicator as well. Have a coding or compliance manager who is certified perform routine coding audits to ensure accuracy. So you've got the good employee, you've got the one that communicates well, you've got the one that's certified, they have GI coding experience, wonderful, but we have to make sure they're also accurate, okay? So you should, your practice has to determine the accuracy percentages, that's part of your compliance plan, but most consider an accuracy rate for a coder of 90% or higher. Review those results with the coder as educational opportunities going forward, repeat coding audits as appropriate. So, you know, if you get a, you've got one that's got an 80%, you work with them, you re-audit them, and you educate them, train them, train them. Obviously, if it's just not getting any better, getting worse, then that's another discussion. Again, book, chapter versus key, you utilize your AMA CPT guidelines, your ICD-10 guidance, and your payer policies. Set up productivity standards within your practice, so productivity can vary by what types of records that are audited. And this is more like, again, what do you have in front of you? I can audit basic endoscopies very, very quickly. Kathy and I were actually having this conversation yesterday a little bit about, she's kind of, she can really read through something really, really quick. Me, sometimes I have to go back and read it again and again and again. That's just our styles, okay? And it works for us. But if I have, if I have a stack of basic endoscopies to my left, and I have a stack of advanced procedures and ARCPs to my right, I am not going to be able to do, I'm not going to be able to audit 20 basic, sorry, 20 advanced endoscopy procedures in an hour, okay? That's going to be more like 11, 10, 15, 12, an hour. But if I've got nothing but a basic endoscopy, I can definitely get through 20 an hour. Obviously, give or take. If the coder's new, they're going to be slower at points. Once they get seasoned, they're going to get, they're going to pick up pace. But definitely should make sure that their productivity is there. Visits are different, okay? So if I'm looking at strictly office visits, I'm probably going to be able to audit 20, 25 an hour. But if I'm looking at all consultations, I might only get 15 an hour. So again, you have to look at per hour, you have to look at what are, what are they being asked to audit? Because advanced procedures, ARCPs, those are difficult. And they're one of those where, like, I'll print the op note out, and I'll get my highlighter out, just to make sure I don't, I don't miss any potential technique of billing, et cetera, and modifier usage. Compliance tools. Assign an appropriate member of your staff to review your billing process and develop the compliance plan. Include policies and step-by-step processes for responding to an audit. Review internal billing data to identify patterns that may trigger an audit. And then conduct frequent coder training and provider education, okay? So again, it starts with the compliance. We have to have a compliance plan. But we have to implement and follow that compliance plan. I shouldn't walk into a practice and say, hey, do you have a compliance plan? And they're like, oh, yeah, it's in this binder on the shelf, and it's got five layers of dust on it. That's not a good compliance plan. It's we're working daily, we're working to make sure that quality, we've got quality over quantity, we've got communication, everything's done as correct as we can do them. And again, we've got to relay this information to the people that we work with, communication. All right, so question. How often should internal audits be conducted? Yearly or, sorry, yearly, quarterly, never, that's why we have insurance companies, or every two years? 71% say quarterly, that is correct. Quarterly is good. And most practices do that. You know, they do a random sampling. And the random sampling is, you know, it can be up to you what you look at. You can look at the type. It can be a specific level of service. It could be, let's look at upper endoscopy with biopsy. Let's look at screening colonoscopies. Let's look at this modifier. It could be, let's look at this provider because they're new. It could be, let's look at this coder because they're new. Okay, so, but you have to conduct regular. All right. We should, the one that's doing the internal audit should be credentialed. Okay, should have coding certifications. Again, quarterly basis, determine the type of review. Again, focus on a specific level or just a mixture of visits, procedures, providers, et cetera. Define the scope of your review. Okay, so again, we're still talking about the compliance plan. Best practice is to perform prospective reviews. So, we've got a prospective type of a review and we have a retrospective type of review. Prospective before billing. Retrospective after billing. The reason we recommend prospective is because if you identify that you've billed something incorrectly, guess what you have to do? You have to either reimburse the payer or you have to send in a corrected claim. You have to work to do more work. Okay, so, if performing a retrospective audit and errors are identified, claims should be corrected and any refunds should be made accordingly. Also, once you do that audit, you should have a spreadsheet of what you found. What was wrong? What do we need to correct? Okay, so there should be a coder section. There could be an auditor section, like if I'm auditing a coder. Include any over-coding, under-coding, financial impact, and a comment section. The coder should be given a preliminary copy to explain rationale behind the coding, okay? So, they should be able to defend something if they really are head set on, this is why I did this. A final report should be submitted in appropriate meetings and training should be scheduled. So, meetings should include coder, their supervisor, and a compliance officer. Sometimes, a practice that's one hat, the coder, the supervisor, and the compliance officer, unfortunately, sometimes is one hat and that's okay. So, your audits are going to look a little different. Document efforts to improve coding and billing processes. So, staff training, ongoing education, provider documentation training, and ongoing education, okay? We always have to, we all know coding and billing is an ever-changing issue and as soon as we learn it, guess what happens? They change it, they change it on us. So, we got to know, we kind of stay up to date as much as possible, but again, communicate that to everybody. Don't just keep it at your desk. Identify your problem areas. Was it coding errors, billing errors? It might even be just poor documentation, so then that would go back to the provider. All right, and we'll talk about that in the next section. Determine what corrective action should be taken to avoid improper payments. Track and research your denials as well and keep up to date with CMS policy and your local Medicare contractor guidelines. If you're not familiar with your Medicare contractor or you don't even know who your Medicare contractor is, you definitely should find that information out. Utilize their website. They have a lot of, most of them. Some of them, you'll go down a rabbit hole and it's never-ending, but some of them are very, very good. They have modifier fact sheets. They have, again, the specific diagnosis codes they approved, which is LCDs, local coverage determinations, and then everybody should be aware of them. So if they decide that they're not going to pay, they're not going to approve, if they have an LCD, let's say, on a colonoscopy and they're no longer going to cover iron deficiency anemia and it's off the list, we need to be communicating that because who orders these tests? Okay, it's the providers. They've got to know. Review the OIG, Office of Inspector General, annual work plan to identify potential audit areas as well. They tell you what they're looking at, so you might as well make sure you're doing those things correctly. Monitor your RAC audits as well, recovery audit contractors. We'll get into that a little bit later. And again, can't stress it enough, communication. Billing and coding managers should communicate payer policy changes to coding and billing staff. Coders and billers need to communicate with each other to ensure consistency and coding accuracy. There shouldn't be four of us sitting in the room and we all four do different things, okay, because that's going to come across to a payer as we don't know what we're doing and it's a red flag, okay? So we all should be on the same page. Everyone must communicate back to the provider. They can't fix mistakes if they don't know about them. I can't stress that enough. We, again, we have been in practices where we're going over, you know, I'm in front of the room and there's 50 people listening to me and I've got these, I've got providers looking at me like deer in the headlights and I'm like, what is wrong? Am I saying something wrong? I don't get it. And then we get done and the physician walks over to the coder and says, what is, what does this mean? This modifier should be used for what? And they're like, oh, yeah, I've been just, I've been fixing that for you. I've been just doing it the whole time. And sometimes providers will say, hey, you need to tell me these things. You know, we can't make the provider responsible for knowing every single thing, coding and billing, left and right and up and down. But they definitely need to know the general aspects of it. And if we're changing things, they need to be aware of it.

leading and teaching a coding team

communication

productivity

auditing physicians and providers

compliance plan

coding audits