A few months ago I held a forum for wanna-be coders and much of my presentation was devoted to hospital versus physician coding. By the time I was done, I had several people asking me how to choose between the two. This is an excellent question and one that you need to decide right off because how you proceed with joining organizations and networking will be impacted. First off, not everyone has the skill it takes to be a coder. I have, unfortunately, met and attempted to train a lot of people who just “don’t get it.” Coding requires a great deal of attention to detail that can be tedious to a lot of people. It’s also detective work – once you have all the details, then you need to be able to assemble them and make sense of them. And because these details come from medical record documentation, coders must understand medical terminology, anatomy and physiology, and disease process.
What Makes a Good Coder?
The first question to ask yourself is, do I meet the following criteria?
· Strong medical terminology, anatomy and physiology, and disease process knowledge,
· Ability to piece together clues logically,
· Strong attention to detail,
· Ability to work a full day in front of the computer without a lot of peer interaction,
· Common sense,
· Ability to research and seek out answers to questions,
· And good written and verbal communication skills for those times when you get to escape from your desk.
If you answered yes to most or all of these questions, then you are on your way. If you answered no to most of these, then you should reevaluate becoming a coder. Some things, of course, can be taught, such as medical terminology, anatomy and physiology, and disease process. Other things, like the strong attention to detail cannot be taught.
Hospital vs. Physician
Once you’ve determined that you want to be a coder, you need to decide which healthcare setting best suits you. There are coders for every healthcare setting, but the two major ones are hospital and physician. If you’ve never coded before, you may be wondering what the difference is. After all, there are only a few codebooks (ICD-9-CM, CPT, and HCPCS), so all you have to know is which book to look in right? Wrong.
Besides the coding systems, there are other differences. In a hospital, you are coding for the hospital resources, which include hospital overhead, staffing, supplies, medications, and anything else you can think of that a hospital provides to a patient that costs money. And remember: in most situations, doctors are affiliated with hospitals, not employed by them. On the physician coding side, you are coding for the physician’s time and effort as well as his office overhead. If the physician owns a surgery suite or otherwise utilizes supplies and medications, he may also bill for these items. He cannot, however, code or bill for items that were supplied by a hospital or surgical center where he performed a procedure. What it comes down to is, whoever paid for the item can code for it – this is where common sense comes in!
You may hear experienced coders and billers talk about professional versus technical coding. Professional services are those provided by the physician. So coders working for physicians are always billing the professional component. Technical services are those provided by hospitals or other facilities (e.g., ambulatory surgery centers, rehabilitation hospitals). There are some instances, however, in which a provider (hospital or physician) may bill for both the technical and professional component. For example, there are some physicians who are employed by hospitals. In these instances, the hospital can bill for both the technical and professional components and the physician is paid a salary by the hospital. Another example is of a physician who owns his own surgery center.
Another difference between hospital and physician coding is the information that is coded. In a hospital, the patient’s record is evaluated for the entire visit and all documentation is reviewed including physician reports and progress notes, orders, therapy records, operative reports, labs, and x-rays. In the physician coding setting, the coder is looking only at a particular physician and coding his part in the patient’s case. For example, although a patient may have been in ABC Hospital from June 4-10, if Dr. Smith saw the patient in consultation only on June 5, his coder can only code from his June 5 consultation notes.
The size of the practice or hospital also makes a difference. In physician offices, the coder is also the biller and, as such, must become very familiar with insurance billing regulations. Physician coders are generally also the ones to process and correct insurance denials.
In a hospital, coders are usually part of the health information management (HIM) department where they have easy access to the medical records. In addition to HIM coders there is a computerized system for assigning certain codes on outpatient cases automatically when charges are entered into the hospital’s computer system. These codes are linked to charges using a database that contains all of the hospital’s charges for every department. This enormous database is called the charge description master (CDM), or simply charge master, and codes assigned using the CDM are said to be hard coded. In contrast, the codes that are manually assigned by HIM coders are said to be soft coded. Hard and soft codes come together on the patient bill in the billing department, which is generally separate from coding. If there are any problems with the codes, the billers will send them back to the coders for correction. Once billed, the billers process the denials. So in the hospital, HIM coders are less likely to be familiar with the various insurance billing guidelines.
Finally, coding rules themselves can be different depending on the healthcare setting. One example is the application of the Official Guidelines for Coding and Reporting, which states that the first-listed (principal) diagnosis for a hospital inpatient is the reason established, after study, found to be responsible for occasioning the admission of the patient to the hospital. For physicians, though, the first-listed diagnosis is the reason for which he saw the patient for that episode. Another difference in coding guidelines is for the assignment of evaluation and management (E/M) codes. E/M codes were developed to report physician time and effort in examining a patient and determining the plan of care. Hospitals use E/M codes for outpatient cases, but have adapted the definition to be able to report hospital costs associated with patient care that are not separately reported with a procedure code.
What Type of Coding Setting Suits You?
So you need to determine the type of coding that best suits you. Do you want to work in a small office where you have control over the entire coding and billing process? Maybe physician coding is for you. Would you like work as part of a revenue cycle team and be able to view the patient’s visit episode as a whole rather than just one piece of it? Then maybe hospital coding is right for you. I can’t say which one is better, because I’ve found that people are inherently one or the other. I liken it to being either a cat person or a dog person – neither is wrong or right, it’s just what fits the individual. Can you be both? I think you can be both a hospital and physician coder, but I have yet to meet anyone who is really proficient at all areas of hospital and physician coding – there is so much out there! But that’s part of what I really like about coding… endless opportunities to learn.
Live in Colorado and want to know more? I will be soon announcing an August date for networking. We will meet in “pod forums” with three facilitators demonstrating how to code for physicians, hospital outpatient, and hospital inpatient. This is a great opportunity to see which setting is for you and network with the pros. This event will be FREE so stay tuned…
