Certified Is Good Business

Reprint from RBMA Bulletin, March/April 2017, Pat Kroken

As radiology coding has been either outsourced or automated, we as an industry seem to have paid less attention to the importance of making sure our coders are certified in radiology. The Radiology Coding Certification Board (RCCB) was developed to address the fact other coding certification exams included only a few radiology questions and we recognized the complexity of radiology-specific coding needed a much stronger focus.

In fact, today’s radiology business climate makes it more important than ever to certify coders and put them at the table to help manage these processes so closely associated with revenue generation.

First of all, why certification? Radiology coding is especially complex when compared to other medical specialties simply due to the number of procedure and diagnosis codes involved, as well as the widely varying complexity of radiology modalities. And at about the time everyone gets familiar with the applicable codes, they are updated, combined or changed—so last year’s knowledge is last year’s knowledge. Then we decided to make healthcare more complex by changing to ICD-10, so the energetic waltz of keeping everything in motion became a frenetic whirling blur while we prepared for the new world.

Within that framework, coding is certainty. In an ever-changing environment, there are essential rules—and daunting penalties for failing to know them. On the lower end of the scale, incorrectly coded procedures will be under-paid or denied (or sometimes just not billed at all). It may be a dollar here and a dollar there but the total can add up quickly when practices are processing several hundred thousand procedures each year. The total revenue loss also has the potential to multiply exponentially in the event billing regulations are violated and the group is subjected to investigation and fines.

Radiology-specific coding certification evaluates not only the coder’s proficiency in the various modalities, but also in regard to regulatory requirements as well. (In fact, the compliance aspect of the examination process has often been the downfall of the first-time test taker). In addition, Radiology Certified Coders (RCCs) must maintain a rigorous continuing education program that ensures their working knowledge remains current and again, is a valuable safeguard for the practice.

Unfortunately, coding falls under the same “How hard can it be?” categorization as billing processes overall. Of course you can give a technologist coding responsibilities! They already know anatomy and physiology so that should be enough, right? Granted, techs have an edge when assigned to coding but they too struggle with the unforgiving regulatory requirements and should not be expected to immediately begin paddling when thrown into the pond. They too need the level of comprehensive training that builds competence and having them officially certified in radiology affirms that a level of competency.

Certification and Value. Unfortunately, as pressures to reduce overhead have compounded, we seem to have lost sight of the coders’ value when offered a cheaper alternative through off-shore and/or automated options. Coders, especially radiology-certified coders, are among the billing operation’s more expensive hourly employees so when the emphasis is strictly on cost, the alternatives appear obvious.

When you examine the top practices and billing companies, however, they share some observable characteristics. They have Radiology Certified Coders and they utilize them in key positions. For one, RCCs oversee the automated processes. If you ask any leading coder about the proficiency of any automation option, they consistently report a reliability rate of approximately 70 percent. In other words, automation can be effective for simpler studies but so far, nobody is comfortable with advanced imaging procedures and interventional studies are pulled completely from automated processes. An RCC can probably help “train” coding software but the best combination of person/artificial intelligence involves leveraging the productivity of an individual coder with technology but still having the human in the equation monitor the processes. That monitoring includes working with the physicians to ensure their dictation is clear and complete. The top organizations consistently have a defined feedback loop between radiologists and coders—and a level of respect that ensures effective teamwork.

In terms of off-shore or outsourced coding, the RCC plays a valued role in oversight, auditing and training. Yes, there are some well-educated coders off-shore in terms of their medical training but organizations utilizing these resources report some common problems. The group outsourcing may discover their off-shore counterparts have rudimentary coding knowledge, but not be ready for the intricacies of radiology. So they spend a lot of time communicating, auditing and correcting. And about the time the operation is running smoothly, the coding contractor picks up a new, large client and those now-proficient coders are moved to lead a new team—and your team inherits some entry-level employees, so you start over again.

The commonality of these top organizations? Reliance on their RCCs as highly valued subject matter experts within the organization. The groups value and promote specialized radiology knowledge, recognizing the fact their coders help ensure a sound business infrastructure. A strong coding core is closely correlated to strong business performance.

And Now MIPS/MACRA. The Medicare movement to “value based” compensation uses the Physician Quality Reporting System (PQRS) program as the foundation for the Merit-Based Incentive Payment System (MIPS). Quality under MIPS is not measured by physician education and qualifications but rather, how effectively the organization can document performance of key measures so accurate documentation is critical. If a certain percentage of the group produces inadequate documentation, the entire group is penalized by a reduction in Medicare payments for the following year.

On the up-side of MIPS, the groups who satisfactorily report comprehensive, accurate information get a share of the pool of money created by those who are suffer reductions. For a while, until everybody learns to play the game, the rewards can be substantial.

MIPS documentation is right up the alley of certified coders, who would make great team captains for the MIPS initiative—with the minimal goal of stopping the revenue leakage as they work with radiologists to refine dictation until all “t’s and i’s” are accounted for, and the maximum goal of reaping the windfall as a reward for diligence.

Steps to Certification. The Radiology Coding Certification Board (RCCB) offers its exam several times each year, with dates and details outlined on their website at www.rccb.org.

In addition, the RCCB has partnered with Coding Strategies to develop an array of proficiency assessments, which are valuable not only as continuing education options for certified coders but enable newer coders to self-test their current levels of knowledge and identify areas needing further study. In fact, the proficiency assessments offer an excellent opportunity for practice leaders to review coding staff baseline knowledge by modality.

The cost/value pendulum is beginning to swing away from the cheapest option, which has too often yielded disappointing results—and is beginning to focus again on value for the investment. Again, the leading organizations are the ones who have successfully invested resources to ensure they have the right people in the right places. They are the ones who have successfully balanced the interplay between leading technology and a skilled workforce—or the interaction of off-shore coding and a knowledgeable auditor/leader stateside. And they know an investment in “certified” is good business. It’s a path anyone can choose to follow. Are your coders radiology certified?