By Ruth Carol, contributing writer

You know that you’ve done the appropriate procedure, but do you know if you will be paid appropriately for it? If you had a good medical coder, you would know.

“A good medical coder correctly captures the services performed and makes sure they are accurately coded so that the provider gets fairly reimbursed for what he or she does,” said Carly Aliff, CCS-P, central business office director for Buffalo Medical Group in Williamsville, New York. A good medical coder also avoids any unintentional fraudulent billing.

“They safeguard the bottom line for the providers and keep them out of hot water,” added Cyndi Stewart, CPC, COC, CPMA, CPC-I, manager of coding and reimbursement resources at the American Academy of Dermatology Association (AADA). Experienced coders can recognize the reason for a claim’s denial, and develop and file appeals based on coding guidelines and payer policies versus billers who may not have any coding knowledge. “I have seen billers who just throw on one modifier after another to try and get a claim paid,” said Stewart. “Experienced coders can recognize the problem on the first pass and get it corrected.” Repeatedly resubmitting a claim can send a red flag to the payer, she said, and the last thing a dermatologist wants is to get audited. 

Why front desk or billing staff don’t add up

Some of the best medical coders that Aliff has worked with started out as front desk and billing staff or medical secretaries and assistants. “They have a more well-rounded knowledge and understanding of what happens in the exam room better than someone who just went through a coding course,” she said.

But that doesn’t mean that dermatologists should expect their front desk staff to serve double duty as coders. Typically, front desk personnel are busy answering telephone calls, scheduling appointments, and speaking with incoming and outgoing patients, noted Alex Miller, MD, who is in private practice in Loma Linda, California. Even if they had time to do coding, they would constantly be distracted by their other duties. Those include collecting and entering pertinent information into the practice management system to avoid errors that ultimately may result in claim denials, noted Theresa Schoepf, AAHCA, CDC, the billing supervisor at New Image Dermatology in New Port Richey, Florida.

Another reason that front desk staff, and even billing staff, shouldn’t be coding is because they don’t have the fundamental knowledge and training that a certified coder does, which could lead to errors, said Aliff, who started out as a medical assistant. It takes time, dedication, and training to review and understand the provider’s documentation, take that information and correctly interpret it into procedure and diagnosis codes, and then apply the payer policy, Stewart noted. Typically that training is not afforded to a front desk staff person.

Job responsibilities

The qualifications, experience, and characteristics that should be included in the job description depend on what the medical coder will actually be doing — which is often determined by the size of the practice and how it is set up.

“A coder could just determine the codes, but a coder could also be the person who does all the billing and processing, adjudicates the claims, pursues non-payments, and determines how to address denials and which claims should be appealed,” said Dr. Miller, who is the current AAD advisor to the American Medical Association Current Procedural Terminology (CPT) Editorial Panel. The larger the practice, the more likely the dermatologist will want to employ a coder, preferably one who is trained in dermatology, he added.

In some practices, the provider selects all the codes and the coder just enters the codes and does follow-up on the back end, said Stewart, who has 20 years of experience as a coder. In other practices, the provider only documents the charts and the coder reads the charts and codes everything. At one practice where she worked, Stewart read the documentation and coded it, working closely with the provider if questions arose. At another practice, the provider selected the codes for the procedures while the coder checked the provider’s procedure codes and coded for evaluation and management (E/M). “So it really depends on what’s expected of the coder and how much in a silo the coder is working,” she said.

At Buffalo Medical Group, a large multispecialty practice with 200 practitioners at seven locations, the dermatologist selects the E/M from a pick list and the electronic health record (EHR) system drops the code that then goes into a work queue where it is assigned to one of two dermatology coders. The coder reviews the code against the documentation. If it’s correct, then the coder releases it. If not, the coder must provide feedback to the dermatologist, of which there are five along with 12 advanced practitioners in dermatology. The coder then releases the corrected charge.

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Credentials matter

When hiring a coder, credentials matter. Credentials provide proof that the individual has met the minimum competency for coding, Stewart said. Even payers recognize that certified coders have the necessary knowledge. The two primary organizations that provide coding credentials are the American Association of Professional Coders (AAPC) and the American Health Information Management Association (AHIMA). The AAPC offers Certified Professional Coder (CPC®) certification and CPC in Dermatology (CPCD™) certification. AHIMA offers Certified Coding Specialist-Physician-based (CCS-P®) certification and the CCS®, the latter of which is generally for a hospital setting. Aliff only looks for coders with either certification from the AAPC or AHIMA. “I am particular about credentials,” she added.

The AAD recommends hiring a CPCD certified coder because they are trained in the nuances of dermatology that don’t exist in other specialties, Stewart said. For example, once nuance is that some dermatologic procedures have had their value reduced because it is assumed that they are typically billed with an E/M service. This does not mean that you can’t bill an E/M, but if you do, the E/M service has to be significant, and separately identifiable from the procedure.

Having CPC certification is definitely a bonus, but isn’t essential for working in a solo or small practice, said Dr. Miller, who does his own coding after learning the pertinent CPT and International Classification of Diseases (ICD) codes for dermatology, but acknowledges that most dermatologists wouldn’t necessarily want to spend the time doing that. Every staff member, including medical billers, who he has hired were trained on the job.

“Credentials are always good to have,” Schoepf said, “however, in my opinion, they are not necessary.” That’s because the EHR does much of the work at New Image Dermatology, which consists of one dermatologist and one physician assistant. Having said that, she noted that EHRs are not error proof and that’s where having a certified coder is helpful. Schoepf, who has 20 years of experience working in dermatology, has received most of her training on the job.

So you think you can code?

Want to test your coding knowledge? Check out DW’s Cracking the Code quizzes each month at staging.aad.org/dw.