Thursday, February 13, 2014

Billing and Coding Series 1/3: Why It Matters for Students/Residents in Primary Care

For three years before I applied to medical school, I worked in post-Katrina New Orleans helping to rebuild School-Based Health Centers. One of the main challenges however, was how to create a sustainable safety net for at-risk youth to whom we were hoping to provide much needed health services. The key to that sentence was sustainable. All too often, there isn't funding available to carry out our mission in primary care of improving the health of communities and underserved populations. At the time, I was a public health manager, and I remembered I often felt increasingly frustrated at physicians that couldn't optimize their coding and billing because not only were they leaving money on the table for the much needed services they were providing, but they made my job of trying to advocate on their behalf near impossible. One of the avenues we tried to pursue was state funds to support the School-Based Health Centers, but without proper coding, we never had accurate data to show exactly the needs we were addressing. In addition, when we asked state legislators for increased funding, we were easily countered with, "But you don't use the money we're giving you now through Medicaid...". The only thing I could do was stare back looking like a greedy kid who asks for seconds before I finished what was already on my plate.

At the time, I didn't understand why it was so difficult for physicians to code for the services that they were providing. It is part of their job. I remember thinking, "What is wrong with you people?! Don't they teach you how to do your job in medical school or residency?" Now that I've been through medical school and am in residency, I realized... actually no, no one teaches us about how to actually be a functioning physician in the community. We learn about medicine, a necessary part of being a good doctor... but it isn't the only part. We seem to forget that physicians operate in a larger healthcare system that is increasingly being scrutinized for its cost and quality. It is more than just knowing how to diagnose and treat diseases anymore. In our changing healthcare environment, we're going to be expected as physicians to code accurately to prove we've met certain quality measures, justify our billing (let's not forget one of Medicare's major cost-saving strategy is cutting down on fraud, so as a warning coding inaccurately whether it is intentional or not can be considered fraud), and as there's increasing pressure to drive down the cost of healthcare, we can no longer afford to leave money on the table if we want to be sustainable (particularly when working with underserved populations).

It's a deficit in our medical education system that we don't teach basics of practice management to medical students and residents, but then we expect people to graduate from residency with a sudden knowledge of how to do things that will be expected of us as practicing physicians. In this past year I've been promoting the importance of coding and billing, as well as providing some basic information to my fellow residents. I hope by laying a framework, we can continue to learn more throughout our training, and ultimately graduate more prepared to be functional physicians in the community. However, I think this is an important issue for all residents, so I wanted to share some of the things I've developed as a 3 part series so that we can learn together. The second in the series will be an overview of coding if you ever wondered what CPT and ICD-9 (soon to be ICD-10) means, and then the third and last in the series will be how to document clinic notes appropriately for billing.  

Author: Raymond Tsai, MD, MS is a Family Medicine resident at UCLA. MD from Stanford University School of Medicine and MS in Health Policy and Management from Harvard School of Public Health. Follow him on Twitter (@RayCTsai) or see his personal blog about health living.


  1. An emergency room transcriptionist friend has told me that even using the word "accompanying" instead of "associated" symptoms allows the hospital billing team to optimize reimbursement. Is this true? I don't remember that being in Bates (Guide to PE and History Taking).

    Regardless, I'm looking forward to the series! I saw that AMA has training in billing for clinicians, but it's too expensive and i'd rather have an abbreviated version anyways. Seems like a key to efficiency (if i can't reduce my face-to-face time anymore, perhaps I can get reimbursed better)...

    1. Thanks for the comment and reading. To be honest, I'm not sure, I've never done in-patient billing, only out-patient, and I don't remember seeing this issue come up. Does Bates talk about documenting for billing? I should take a look at that, we looked at it in med school, but I don't think we went over billing, or at least skipped those parts in med school.

    2. I don't think Bates does, I was joking... agreeing with you (documenting for) billing is important, but not a core topic if even a topic at all in medical school.