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banknotes as cash

Oct 06

Keeping what you earn

Stop me if you’ve heard this one…  When I first heard about this, I thought, “This has GOT to be a joke.”  Sadly, it is not.

I read about insurance companies purportedly attempting to intimidate physicians and medical office managers into lowering coding levels on claims.  They send a certified letter telling them something like, “We compared your coding usage and find that you’re in the top 5% indicating you may be over-utilizing the higher codes. This is not an audit, yet, but we advise you to review your coding usage to avoid an audit”.

They bank on practices to stop using the higher level codes, at least for a while, greatly reducing the cost for the insurance company which makes investors very happy.  The scheme works something like this:

  1. Convince a provider to lower 1-2 claims each day.  (99214 = $107; 99213 = $74 in Arizona)
  2. They repeat this over 20 – 22 days each month.
  3. Get maybe 10% of PCPs to fall for it (700K physicians; 225K in Primary Care)
  4. Do the math with a maniacal laugh:  $33 x 2 (claims) x 240 (days) x 22,500 (Docs) = $ 356 Million
  5. Rinse and repeat for all specialties in the plan.

Broadly applied to in-patient and out-patient services, this tactic can yield BILLIONS.  As a coding expert I know said:  it doesn’t take much intimidation to get doctors to drop coding levels

I couldn’t make this up if I tried.

Reality reveals many providers often under-code.  This might be due to hearing horror stories about audits early in their careers (with embellishment, no doubt) or from this type of sensitization / manipulation by payers.    

Even if that seed of fear hides in the background, learning and mastering the details that make your notes clearly support your billing choices is something every provider can do. 

The entire workflow from scheduling, to check-in, to screening, to gathering HPI, to the provider – patient interaction, labs, etc., on to billing and follow-up should work together to ensure complete documentation (if it isn’t in the EMR, it didn’t happen…) and the most accurate coding.  The mutually reinforcing data collection and posting supports better outcomes for the patient, accurate credit for quality metrics, and proper reimbursement. 

The tools and processes need to work together.  If yours do not, we can help.  Go to the Services page on our website,, and select the “Get Help” button next to your area of interest.