ACP American College of Physicians - Internal Medicine - Doctors for Adults

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Coding Diagnostic and Improvement Module

Coding is a routine, everyday part of a physician’s career, but how it is done can make the difference between receiving full compensation for the services you render, leaving money on the table through undercoding, or having money taken away due to adverse findings of an external audit. This module presents a simple yet systematic methodology for first assessing the appropriateness of current coding and then undertaking an on-going improvement process designed to optimize future coding. At each stage relevant PMC coding resources and tools are incorporated as direct links. Follow these easy steps to improved coding:

1. Enter your Evaluation and Management (E/M) coding data into the Coding Assessment Tool to determine how your coding patterns compare to the national Medicare averages for other physicians that specialize in internal medicine. While not a measure of coding accuracy, this assessment can quickly highlight any variances that might catch the eye of auditors or be a sign of routine under-coding, a pattern that can erode the income of internists. Because E/M services account for a very high percentage of general internal medicine services, they are a good barometer of coding patterns.

2. After determining how you compare to your peers, conduct an in-house coding audit (see “How to Complete a Coding Audit”) to investigate any variances from the norm and to assess the accuracy of your current coding. Carefully compile a list of the key problems identified by the audit so you can work on improving them in the future. If you think the audit results suggest a need to study the fundamentals of coding, download our guide: “Coding for Internists: The Basics” and listen to a presentation "Coding 101: Getting Paid for What You Do" including case examples narrated by a coding expert.

3. As a daily aide to coding future patient encounters use PMC’s two coding reference sheets: “Commonly Used ID-9 codes” and “Evaluation and Management Service Codes…”.These sheets may be printed directly from the webpage or ordered in more durable laminated form from ACP customer service by calling: 800-523-1546, ext. 2600. Carry or place copies in your exam rooms for easy reference.

4. Periodically repeat the coding audit (step 2 above) to monitor your improvement progress. Audit frequency should be guided by the severity of any identified problems and your success in correcting them. Some practices initially conduct abbreviated sample audits on a weekly basis until improvement is evident and then gradually move to regular quarterly audits. Most practices should incorporate quarterly audits into the on-going routine of their operations to avoid slippage, to assure that new physicians are learning to code appropriately, and to stay current with coding changes.

Page updated: 11-14-06

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