Why physician practice coders need to know the front- and back-end of reimbursement

In a previous post, MMI’s contributing blogger and chief training officer, Dari Bonner, discussed how RMC-credentialed medical coders enhance various business processes within physician practices. This month, I’ll take a deeper dive into the importance of a holistic approach to coder education—and why this matters in today’s regulatory-driven environment.

 A front-to-back approach to coding education

As reimbursement experts who are well-versed in payer requirements, coders are increasingly pulled into various roles within a practice. Coding may only represent a small portion of a coder’s actual responsibilities.

As a result, they must be well-equipped with skills and knowledge to perform a wide variety of duties within practices, medical groups, and clinics. In addition, a ‘big picture’ view of reimbursement enhances documentation, coding, and billing accuracy—including the front-end (registration and documentation input) as well as the back-end (denials and appeals).

When coders have a front-to-back understanding of the revenue cycle, they can articulate the implications of the codes they assign—and know how to improve processes to ensure compliance prospectively. For example, a coder who understands how to build a template in the EMR quickly adapts when new ICD-10 and CPT codes are released. A coder who communicates regularly with payers educates physicians about carrier-specific documentation requirements. A coder who tracks, trends, and manages denials and appeals is able to perform root cause analysis to mitigate denials going forward.

In general, look for coding educational opportunities that touch on these content areas as part of a single course or as a series of courses:

  • Anatomy and physiology
  • Denial management and appeals
  • Auditing
  • Billing
  • Clinical documentation improvement (CDI)
  • Coding (including carrier-specific coding)
  • Credentialing
  • EMR navigation, code validation, and template construction
  • Practice management
  • Registration

From a coder’s perspective, why is a holistic approach important? Two words: Job security.

Preparing for the future

Coders who possess knowledge of each of the topics listed above are far more marketable than those who don’t. These content areas are critical regardless of the size of the practice or medical group.

In addition, each clinical specialty carries revenue cycle nuances important for coders to understand. For example, there are a number of procedures for which an NCD or an LCD specifies documentation requirements, including prior treatments and their efficacy as well as billable diagnosis codes.

Many payer-specific policies also limit the frequency of a particular procedure as well as a total number of times that procedure is covered during a specified timeframe. Coders should have a working knowledge of the policies that apply the unique patient mix for the practice in which they work. As the industry moves forward—and regulatory requirements continue to mount—physician practices will continue to rely on credentialed medical coders who bring a wealth of knowledge to the table. This includes a superior knowledge of coding intricacies and requirements as well as the ability to manage other all aspects of physician practice reimbursement appropriately.

About the author

Karen M. Fancher, MD, RMC, CPC, CANPC, CFPC Dr. Karen M. Fancher is a residency-trained Family Physician who also completed a fellowship in Advanced Women’s Health. Dr. Fancher is an AHIMA-approved ICD-10 trainer and holds specialty coding credentials in Anesthesia and Pain Management as well as Family Practice. Dr. Fancher currently serves as the Educational Trainer at the Medical Management Institute where she is able to assist working certified coders & billers. Dr. Fancher has 20 years of combined experience in the healthcare field, including clinical practice, medical coding, and medical records auditing. She has written presentations on Evaluation and Management Coding for Physicians as well as ICD-10-CM Documentation for Providers and remains committed to helping providers improve their documentation in order to help their coders and billers maximize legitimate revenue.