Reimbursement coding is the process of translating physician and nursing documentation into billing codes. And Brault believes that a clinical mindset is the key to recognizing all billable services. In fact, our experience confirms that someone clinically trained in patient care will perform a more accurate translation than someone trained only in medical terminology and coding policies. This is why Brault invests in Nurse Coders – they add value to our client’s bottom line results.
Coders have to read the subtle clues to the physician’s thoughts about the case and must translate those thoughts into each payer’s own language. Only Nurse Coders can perform these tasks effectively. Otherwise, why would insurance companies employ them to audit physician records?
Consider this, in just the emergency department, there are more than 500 distinct physician services rendered in the emergency department that can be reported for reimbursement purposes, and an endless number of ways that these are documented by emergency physicians.
The key to capturing all billable revenue is to understand what each service is and what documentation is considered acceptable by each payer.
Reimbursement Coding by Experienced Nurses
Registered nurses – many with direct acute care experience – perform most of Brault’s reimbursement coding functions, reviewing the medical record, and determining the billable services documented by the treating physician. For every billable service, we assign the appropriate CPT and ICD-10-CM code to ensure equitable reimbursement.
This clinical acumen and expertise, which other billing companies are unwilling to invest in, enables our nurse coding specialists to ‘think like physicians’ and apply a clinical logic to reimbursement documentation.
Nurses know firsthand the vital but subtle nuances of charting patient data. Their advanced medical training enables them to instinctively understand the interplay between dozens of complex factors, such as: the patient’s age and history (relevant to their presenting complaint), number and purpose of medications, meaning of exam findings, lab values and diagnostic studies, as well as results of nursing interventions, and available management options. The ability to follow the acute care physician’s perspective, as well as the payers’, makes Brault’s nurse coders more effective at appropriate charge capture.
Proprietary Training for Clinical Understanding
In medicine today, there is a constellation of complaints, co-morbidities, patient history traits, treatment options, studies and interventions that practitioners must know about and consider. But, coders must also be fluent enough in this constellation to know which information is relevant, and which constitutes additional complexity.
And while coding “certification” by trade associations can a useful measure of a coder’s willingness to seek independent verification, it does nothing to assure that coders have the clinical tools they need to appreciate medical decision-making. In fact, the result of a non-clinician coder is often significant under-coding, a pervasive and relentless problem for most billing companies.
So, for our team of nurse coders throughout the country, Brault combines a proprietary certification program with frequent quality assessments and ongoing education on code definitions and reimbursement regulations.
Our coders are even trained to identify instances where critical care and observation care are being performed, but not adequately documented for billing purposes. By recognizing the clinical indicators that represent a “high probability of imminent or life threatening deterioration,” our coders can add extra value by prompting individual physicians to document time of attention (even days after the chart was presented for coding).
Coding Integrity and Compliance
True integrity requires a commitment to doing the right thing the first time and every time. As a matter of corporate compliance, we follow all applicable Federal, State and County government regulations and the provisions of your Practice’s agreements with third party payers. Brault administers a proprietary compliance program that is more stringent than the medical billing compliance model published by the Centers for Medicaid and Medicare Services (CMS). And to further promote compliance and avoid inappropriate provider behavior, we do not prompt for missed data elements incidental to the history or physical exam.
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