Avoiding the Shoals of Contracts and Codes
The medical billing process is based on codes that are marked down for each visit. There's one type of code for the visit itself, which depends on the appointment's length and complexity. There are also codes for procedures—everything from heart surgery to a flu shot has a distinct code. Each of these is then linked to a separate diagnosis code—what the visit or procedure was for. This seemed simple enough. But when the coding and compliance specialists—Karen and Linda—started explaining the details, nothing they said made sense. I recalled a time when I'd tried to speak French with someone who was Belgian; the words sounded right, but no actual communication occurred. I wondered if, as on that earlier occasion, it would be better to use hand gestures.
Karen began. "You've got your basics, your E and Ms, and your preventatives." I took a breath to ask what these termsmeant, but she had alreadymoved on. I vaguely remembered having heard "E and M" somewhere before. Random paired letters flashed through my mind: A&P grocery stores, A&Wroot beer, B&O railroad . . . Wait, I had it! "E and M" stood for "evaluation and management," the code for a visit about a problem.
I struggled to catch up to what Karen had been saying in the meantime. ". . . remember that follow-ups are different than news, although if a new has been seen by someone else in the clinic in the past three years they're not new, unless it wasn't your specialty. Remember if it's a consult you have to code a 902 series instead of a 992 series. You have to dictate the referring practitioner or it's not a 902. Remember to differentiate a consultation froma referral, although that won't affect you so much—you're a primary care."
What's the difference between a consultation and a referral? I wondered, but Karen's tone suggested I should have learned that at my grandmother's knee, so I was afraid to ask. Then I thought, I'm "a primary care"? I've been through eight years of training, and after two days of practice I've already lost "doctor" from my title?
I wrote down "902/992" on my notepad and hoped it would mean something later.
"You can use V codes, but remember
I had a long and baffling meeting with the people from the Coding and Compliance department. They had the unenviable task of teaching me in a few hours how to bill for the work I do.
they're not always reimbursed," Karen continued.
"V codes?" I asked weakly.
Karen nodded but didn't elaborate. "And when you've got an eight or nine hundred then you need to remember your E code; nobody likes it but it's important or the claim will get denied."
"Well, they won't pay for anything if they think someone else should be paying it. Like L and I."
L and I . . . Yes! That meant Labor and Industries, the federal department that administers workers' comp. I was thrilled to recognize an abbreviation but still didn't get what Karen had just said.
"I'm sorry," I admitted, "you lost me there again. Eight or nine hundred? E?"
Linda sighed as if I were a particularly
truculent child. "Eight or nine hundred codes are things like injuries and accidents. Es are circumstances, location, and causes. Someone has a broken arm, you have to code an E for how it happened—motor vehicle accident, fall—or else it doesn't get paid. Or if it was at home you code that, versus if it was at work and then it would go to L and I."
I wrote down, "8-900, E." I was starting to feel a little nauseated.
"But remember, the eight or nine hundred has to be first," Linda added. "E is always a secondary code."
"E secondary," I wrote down on my pad.
Through most of the process of orienting myself to the clinic I'd been excited, albeit nervous. Yes, there was a lot to learn, and yes, this would be different from being a resident. But this was it—it was real, it was what I'd been working toward all these years. By the end of the Coding and Compliance session, however, I was a quivering wreck.
"I can't do it," I announced to a friend that evening. "This whole thing is a terrible mistake. I just can't do it."
"Of course you can," my friend said. "You've learned everything else you needed to, all along the way. You can do this, too."