"In the first quarter after I implemented this system, my total surgical reimbursement increased by 75% over the prior year," Gill says. "Additionally, the average number of reimbursed CPT codes per case increased by more than 46% - from 1.6 to 2.34."

When not done electronically, errors often happen with coding because doctors may forget something, not dictate or interpret properly or just not know an updated code.


"There are a lot of new codes and changing codes so it's good to be automated because the codes may not be the same from year to year" Gill says. "It's more of a mistake thing where you are not submitting everything correctly. Most software packages are becoming easier to use so you will get comfortable with the system quickly."

An accurate electronic reimbursement will be made in a week or two, while paper can cause claims to jump into months. Again, it's simple. Code properly and you will be paid properly.

But the system in place doesn't always make that easy.

According to Gill, over the last two decades, medical coding and the reimbursement process have become even more complex, with payments usually determined by the CMS resource-based relative value scale. This system assigns a relative value unit (RVU) to service(s) performed and uses a conversion factor to arrive at reimbursement. The RVUs assigned for a given procedure are based on three components-physician work, practice expense, and professional liability insurance-with adjustments for regional variations.

In 1996, Medicare made things even more difficult with the implementation of Medicare's Correct Coding Initiative, which introduced additional complexity to the system. The CCI is a collection of rules or "edits," which specify the conditions under which multiple CPT codes may be used. Code pairs are assigned either a 1 indicator or a 0 indicator. A 1 indicator means that the two CPT codes may be used together if certain conditions are met; a 0 indicator means that the two CPT codes will not be reimbursed together under any circumstance. If a physician bills for both CPT codes despite the 0 indicator, the payer could disallow the code with the higher reimbursement.

Because these rules are updated quarterly, the codes change frequently and confusion sets in. That's why it's important to update your software, because that makes things much simpler for the health care professional.

"The pressure to code correctly comes from multiple sources, including payors, hospitals, practice administrators, and even other physicians within the group," says Gill. "Nor does it make any difference what type of practice you have-whether you are a solo practitioner or part of a multi-specialty group or an academic institution. But when payors continually change reimbursement amounts, and the coding structure continues to evolve and become more complex, correct coding gets complicated."

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