How medical practices get a return on CDI and better coding

by Healthcare IT News

Let's forget about ICD-10 coding for a moment. Let's talk about how medical practices can make more money.

There's an urologist in South Carolina who figured it out:

"Two years ago Larry Rabon decided to do things differently. He was going to find every code that he was missing, and bill for that." (via Marketplace)

This isn't exactly found money. He has to work for it. He has a medical billing team (his family) dedicated to staying on top of how to code every diagnosis and procedure that Rabon is legally entitled to submit for reimbursement. And for all of this to work, he has to have the appropriate, specific documentation.

Deborah Grider, a senior manager at Blue & Co., emphasizes the role documentation plays.  "If we don't document well, and we don't have the specificity,  our medical necessity isn't going to be realized so we don't get paid," she says.

Now that's the stick. Without the proper documentation, there can be denials and suspended claims with requests for more information.

But there is a carrot to documenting procedures and diagnoses better. "Physicians tend to think to think that payment is derived only by the procedure code ," says Grider. "That's not necesarily true. It's driven primarily by medical necessity which is the diagnoses that they report on their claim."

"With appropriate documentation, ... If they're capturing everything they're managing from a diagnostic perspective it could increase their level and their reimbursement."

Basically, the clinical documentation improvement (CDI) strategies that will help a medical practice capture the specificity for ICD-10 (diagnoses) coding, will help them make more money using ICD-9 and CPT (procedures) codes now.

"I fully believe it has benefits now," says Grider. For example, consider a patient with colon cancer. "You use an unspecified code, it keeps your reimbursement at one level. If you have other conditions that are contributing, or you have cancer that's matastesized to another area by reporting all those other conditions, it could drive it up to a higher risk, more complexity of that patient care, which could raise that level of service. And they can do that now."

Hospitals realize this. That's why they can afford dedicated CDI specialists. Rabon realizes it works for medical practices also.


Carl Natale blogs regularly at ICD10Watch.com.

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