Professional Fee Coding is the Next Big Risk to Your Organization – Eliminate These Risks to Save Your Bottom Line
Many facilities, when completing a merger or acquisition, bring together professional fee coding and facility coding departments in order to increase productivity and claims reimbursement, but that’s easier said than done1. The YES Team of qualified HIM experts is happy to help you implement these strategies at your facility. We would love to discuss your goals for your ProFee team and develop a plan today!
These healthcare facilities must first consider if they have the knowledge base to accurately document and code professional fee services. The risks of inaccurate professional fee coding could be detrimental to your organization’s revenue and overall success. In our experience as Professional fee coding consultants, payers are increasingly denying claims. They are also requesting additional documentation from providers, who need assistance dealing with complex coding scenarios.
The questions, “What is pro fee coding?” and “Why is it different than facility coding?,” are common curiosities among health information professionals. From our experience as HIM coding and auditing consultants, we have developed the article, “Weighing the Differences and Similarities of Pro Fee Coding and Facility Coding,” which discusses Pro Fee coding guidelines. The article also features helpful Pro Fee coding examples and the various differences and similarities from facility coding.
Furthermore, you can find more information on how to handle discrepancies in our article, “Top 5 Tips for ProFee Physician Discrepancies.”
What are the Risks of ProFee Coding?
Professional fee coding guidelines feature more complex coding scenarios. These are for specialties, procedures, and E/M that – if done incorrectly – could pose risks to the facility’s compliance and revenue.
The first risk of ProFee coding focuses on Relative Value Units (RVUs) versus reimbursements. If a physician utilizes more time and resources than what is reflected in the RVU, that means the compensation does not adequately capture the work performed, and the services have been undervalued. As a result, the bottom line will suffer.
Since ProFee coding deals in treating specialties, the codes and guidelines to report such treatments can be very complex. In our experience, the specialties with the most complex guidelines and anatomy for coding are neurosurgery, orthopedic surgery, and plastic surgery. We have experts in all of these areas to assist our clients with this complexity.
Insufficient documentation poses a risk to any type of coding, but especially to Professional Fee coding. The different levels of E/M codes are dictated by medical decision-making or total time. If there is not enough documentation to indicate how much time was spent with the patient or the complexity of the visit, the wrong E/M code will be selected and can cost the physician a large volume of revenue. For example, a level 3 office visit 99213 is currently 1.3 wRVUs, while a level 4 office visit 99214 code is currently 1.92. Over time, this could lead to thousands of dollars in lost revenue without the proper documentation.
How to eliminate the risks
Here are the five most effective strategies to eliminate professional fee coding risks:
- Quality coding audits ensure the organization’s team maintains high levels of accuracy and productivity by providing robust analysis reports.
- Standardized coding policies and guidelines set an accuracy level that the coding team can strive to. They also keep the facility compliant.
- Coding support services can help your team tackle a backlog of coding needs.
- Coding education programs keep your coders up-to-date and compliant with the latest coding guidelines.
- One-on-one coder mentoring sessions help resolve questions that arise in professional fee coding operations.
Additionally, you can find more detailed information in the Professional Fee Coding Quality Improvement Plan case study by our YES Team. This study thoroughly analyzed all the risks and challenges healthcare facilities face after a merger or acquisition. Over 33 months, the case study saw a 17% increase in the coding team’s CPT accuracy rate, an 18% increase in DX accuracy, and 100% coder retention. Also, by implementing the five core strategies outlined in the plan, the facility successfully conquered its professional fee challenges. Read an overview of the Professional Fee Coding Quality Improvement Plan here, written by Karen Youmans, CEO/President of YES, and Vanessa Youmans, Vice President, Coding Services, and published in the Journal of AHIMA (2019).
The YES Team of qualified HIM experts is happy to help you implement these strategies at your facility. We understand that every organization is unique, so we would love to discuss your goals for your ProFee team and develop a plan today! If your facility needs support or guidance, contact YES HIM Consulting today! Review this article for additional examples of ProFee coding.