professionals. Pro-fee coders may not have been provided with
constructive feedback in the past, so providing them some mentoring time will be essential to the success of both the pro-fee
coder and the merged healthcare system. In addition, training
on various coding tools (e.g., encoders, NCCI manual, NCCI edits, coding references, etc.) may be needed.
The coding support pillar of a coding quality improvement plan
should include a question queue serving physician group pro-fee coders for questions that may arise during their day-to-day
operations. Results from coding support can be gathered and
implemented in tailored education programs and one-on-one
coaching meetings for the physician group pro-fee coders.
More complex providers or specialty groups may need to be
transitioned to a more experienced pro-fee coder until a transition plan can be developed to bring that complex specialty coding back to a physician group pro-fee coder. This transition plan
can include additional education and training for the selected
pro-fee coders. Coding support may also include ongoing dialogue discussions with physicians and surgeons. This should
encompass coding management involvement to answer any
questions from physicians and pro-fee coders. Conference
calls may need to be scheduled for continual physician and
coding professional feedback.
Coding Education Programs
The fourth pillar is implementing a coding education program.
Many of the pro-fee coders may not have had the previous opportunity to be cross-trained in various specialties. They may
not have any formal training in the specialty they currently code.
In addition, provider specialty-specific coding educational programs may need to be developed. The educational program takes
the physician group pro-fee coders through a re-review of medical terminology, anatomy and physiology, ICD-10-CM diagnoses,
and CPT procedural coding for each specialty (e.g., orthopedics,
neurosurgery, cardiovascular, general surgery, etc.). A comprehensive education program should include lectures, conference
calls, webinars, homework assignments, periodic review of ICD-
10-CM and CPT coding guidelines, example exercise completion,
online quizzes, comprehension testing, and a final exam.
Coding Policies and Guidelines Standardization
It is not uncommon to find that there are very few, if any, writ-
Addressing Unique Challenges
ten coding policies for acquired physician groups or that the cod-
ing policies differ from specialty to specialty. When a healthcare
system acquires new pro-fee coders and additional coding re-
sponsibilities, coding managers should begin to gather any and
all formal and informal written coding policies and guidelines.
Within the coding quality improvement plan, it is imperative to
standardize the coding policies and to align them with all official
coding guidelines and your internal healthcare system compliant
coding guidelines and policies. For example, for pro-fee coding,
is it appropriate to code diagnoses from the admitting history and
physical performed the day before the actual surgery? Or are the
diagnoses codes for the pro-fee surgery only to be taken from the
operative report and pathology report? A standardization of the
coding policies and guidelines will be crucial for both the pro-fee
coder and the auditors. One important tool resulting from a cod-
ing quality improvement plan could be the implementation of
a pro-fee coding handbook. A transition plan can be created by
the coding management team with the objective of presenting a
documented structure for the physician group pro-fee coders to
benefit from a successful knowledge transfer and more consistent
coding practices, while maintaining high coding accuracy rates.
M&A activity in physician groups will continue to increase. This
can expand a provider's footprint in the market. Identifying the
new, unique challenges that result from all this change, and
then tailoring steps to address them, is imperative to the quality of medical coding and its impact on a healthcare facility’s
The best approach to addressing these challenges involves
assessing and developing a plan with a holistic approach that
positively impacts coding quality on an enterprise level. This approach requires an objective team with high accuracy rates and a
high level of expertise in the pro-fee coding, and proven experience in coder mentoring and education. A few recommendations
and considerations on the practical side are also important:
Recognize the differences between facility CPT coding
versus pro-fee CPT coding
Acknowledge the importance of interaction bet ween coders and providers
Assess pro-fee coders’ experience and expertise
Provide education to providers and coders
Standardize guidelines and procedures
Measure performance for continuous improvement ¢
Physicians Advocacy Institute. “Updated Physician Practice
Acquisition Study: National and Regional Changes in
Physician Employment 2012-2018.” February 2019.http://
Karen Youmans (kyoumans@yes-himconsulting,com) is president/CEO,
and Vanessa Youmans ( email@example.com) is director
OP/ProFee coding and auditing division of YES HIM Consulting, Inc.
Quiz ID: Q1939009 | EXPIRATION DATE: OCTOBER 1, 2020
HIM Domain Area: Clinical Data Management
Article—“Coding Quality Improvement Plan Implementation for
Hospital-Acquired Physician Groups”
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