The Coding Aspect of the Business of Medicine

Abstract

How many physicians decided to go to medical school to become “the best coder in the country” or “an expert on Medicare rules?” None of them did. Physicians went to medical school to diagnose and to treat patients. The business of medicine, however, relies heavily on codes and regulatory policies to determine how health care dollars are spent. While the success of a physician practice is not dependent upon physicians being experts when it comes to coding services, physicians have two powerful motivations to pay attention. Correct coding ultimately drives the practice’s revenue and also creates the biggest source of ongoing compliance risk. This chapter will provide an overview for physicians of the coding and payment policies that impact the operation of physician practices. The key areas of focus will be procedure and diagnostic code sets and how they are used on physician practice claims; how modifiers are used to describe special circumstances of an encounter, including definitions for the most commonly used modifiers; the Medicare Physician Fee Schedule; and reimbursement policies that can derail claims even when they are coded correctly.