Podcast Episode 1: Introduction to Unraveling Medical Coding: The Complexities of Medical Coding and Billing
Episode Summary: Medical coding and billing is complex. The International Classifications of Diseases version 10 (ICD-10) and the Current Procedural Terminology (CPT®) code sets are expansive. Furthermore, proper medical documentation using the Medicare Evaluation and Management Documentation guidelines from 1995 and 1997 make efficiency challenging. Host Neal Sheth interviews Dr. Piyush Sheth, author of Coding Solutions – General Surgery and Starting Medical Practice, to provide a brief overview of this complexity and his drive towards efficiency.
Resources:
Gallbladder chapter from Coding Solutions – General Surgery
https://drive.google.com/file/d/1KGFBdefXmed8GRB1zTA8MDNGaWPSumwD/view?usp=sharing
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Hosts: Neal Sheth, CGSC; Piyush Sheth, MD, FACS, DABS, CGSC
Welcome to the first episode of Unraveling Medical Coding, a podcast focused on exploring the complexities of medical coding and billing. One of the prerequisites for this podcast is that you should have some knowledge of medical terminology. The podcast is intended for Healthcare providers and Professional Medical Coders.
NEAL SHETH: You’ve been a general surgeon for the last 25 years, going from solo practice to single specialty group private practice and finally to being an employed physician. All along, you've been trying to find ways to make medical coding more efficient. This podcast is an extension of your quest to reduce coding errors. To that end, you’ve actually written a book to help general surgeons called Coding Solutions: General Surgery. Tell me more about that.
PIYUSH SHETH: A quick disclosure. This podcast is an independent work with no ties to my employment with OhioHealth and all opinions are my own.
Coding Solutions: General Surgery is geared mostly toward Healthcare providers and professional medical coders who code for general surgeons. It includes medical documentation guidelines and relevant diagnostic and procedural codes, known as ICD and CPT respectively, into a very intuitive, succinct and very affordable General Surgery specific reference. It is available on Amazon, and I hope will become a primary go-to resource for anyone who does medical coding for General Surgery.
NEAL: Let’s talk about Medical Documentation and Medical Coding. You undoubtedly must document your services before you can bill for them. Is this easy?
PIYUSH: Not really but you get used to it. Medical Documentation is a very important step prior to selecting medical billing codes. There’s a saying in medicine, “If it is not documented, it wasn’t done.” In fact, Medicare developed two sets of Medical Documentation Guidelines, one in 1995 and one in 1997. They encompass three areas, history, physical examination, and medical decision making and they deal with the criteria needed to document certain billing levels of services. These services are called Evaluation and Management Services.
Healthcare providers that are mostly outpatient based have felt these guidelines to be burdensome and distracting from patient care. In response to this the American Medical Association developed different documentation guidelines for outpatient office type services, and these were implemented on January 1, 2021 by Medicare. Other Evaluation and Management services that are provided in a hospital, ER, ICU, etc. still need to use the 1995 or 1997 guidelines.
NEAL: So, once you have documented a patient visit, you just pick a code for billing?
PIYUSH: Logistically it’s a little more complex than that. You first choose a diagnostic code that represents the diagnosis for which you are seeing the patient for. Then you choose a procedural code. You are answering the questions: what is the patient’s medical diagnosis and what did I do for the patient? These codes are submitted to a patient’s health insurance company and hopefully result in payment to you. If the codes are incorrect, the health claim will be denied resulting in no payment. Denied claims are called dirty claims and they have to be reworked and resubmitted but this takes time and effort. In general, the goal is to submit a clean claim on the first submission.
NEAL: Can you explain these diagnostic and procedural codes a little more?
PIYUSH: The current diagnostic code set is in its 10th version and is called the International Classification of Diseases. In the United States, The World Health Organization version is modified by Medicare and is called ICD-10-CM (CM standing for clinical modification). There are over 70,000 codes. Let me repeat that. There are over 70,000 diagnostic codes. The Optum360 printed book containing the codes is 1,330 pages long.
The current procedural code set is called CPT (Current Procedural Terminology) and is maintained and copyrighted by the AMA. It has the Evaluation and Management services codes as well as procedural codes for nearly all procedures performed by healthcare providers. The print version of the professional edition is 1,192 pages long.
NEAL: And I'm assuming electronic resources aren't much better.
PIYUSH: That’s correct. They are pretty archaic, inaccurate, and often frustrating. We’ll be talking more about this in a future podcast episode.
NEAL: So how does your book compare to these other references in efficiency?
PIYUSH: First, my book is portable, under 150 pages. Second, it contains about 98% of the common diagnostic and procedural codes that I use in my daily practice as a General Surgeon. Thirdly, it is organized by Organ Systems making it a very intuitive organization structure. ICD codes and less so CPT codes are not organized in this intuitive manner. So, I've done all the leg work and pulled it all together. Lastly, it is extremely affordable. Please note that the ICD10-CM and CPT code books are the “official” references, and my book is only to be used as an efficiency adjunct. My book is the first reference of its kind and I hope it prompts other such references for other specialties. It took me three years to polish it for publication and along the way I threw in other efficiencies, such as Documentation Guidelines and EMR best practices, to make it a great reference.
NEAL: You can find a link to download the Gallbladder chapter of the book in the show notes. Check it out! You also published another book right Dad?
PIYUSH: Yes. Residency and Fellowship lack formal education when it comes to medical documentation and medical coding. Most physicians learn haphazardly and by trial and error. Your sister, Saloni, a pediatric resident, had a brilliant idea of writing a book about that and we published Starting Medical Practice. In it, we teach new physicians the things I wished I'd been taught coming out of residency, mainly, how to document well and code efficiently. It is also available on Amazon and is also very affordable.
NEAL: In our next episode, we will be talking about the new outpatient office type service Documentation Guidelines.