Code breakers: The importance of unlocking Medicare code

Good coders can find overlooked revenue. Where do you find them? You can train someone, hire one to work in your office or outsource to someone coding from home.

By Robert Kazel, AMNews staff. June 30, 2003.

Oh, what a difference a digit makes.

Sandra Clement, the office manager of a small surgical practice in Rockport, Maine, often coded bills for the replacement of pacemakers. For years, when doctors at her office changed the pacemaker for a Medicare patient, she entered the billing code as 33213 -- the Medicare designation for insertion of a pacemaker pulse generator. The practice received about $400 per procedure.

But then Clement, who had been doing billing for the group for 27 years, attended a 15-week course on coding, and earned the rank of certified professional coder. In the process, she mined some coding gold nuggets -- such as how and when to use Medicare code 33233, for removal of a pacemaker. Billing the two codes together for both halves of the procedure, she was taught, could approximately double her doctors' reimbursement.

Clement contacted Medicare and refiled for a dozen undercoded pacemaker procedures, bringing in about $5,000. That repaid the practice for what it had spent on her coding course, and then some. "The doctors were quite happy," Clement recalls. "It was just something that escaped our practice."

With that kind of money at stake, and the liability for everything a coder transmits to payers, more doctors are realizing that coding can be complex enough to require assistance, those in the coding industry say.

Small changes in procedural or diagnostic codes, unearthed by an educated and attentive coder, can be key to unlocking sources of money doctors overlook. Some experts estimate that a typical family practice may lose between 10% and 20% of its potential income because of poor coding practices. Data published by the Journal of Family Practice suggests that family physicians undercode or overcode almost half of the time.