Q&A: Documentation challenges in single-path coding

Q: How do you personally define single-path coding, and how has that definition evolved from the traditional dual-path or siloed models of the past?

Lolita Jones, MSHS, RHIA, CCS, CRC, CPC, CPC-I, product owner, professional coding for TruBridge: For a patient encounter, [single-path coding means that] one coder assigns the codes for the facility, and for any practitioner whose coding and billing is performed by the facility.

Traditional coding involves a patient encounter being coded by two different coders working in separate departments, neither one of them knowing if their coding is aligned or not. The burgeoning increase in hospital acquisitions of private practices, and the increase in practitioners employed by hospitals, has driven many hospitals to rethink the siloed model of separate coding departments.

Q: What documentation challenges tend to surface when one coder is responsible for both facility and professional coding for the same encounter?

Jones: Documentation challenges surface for outpatient evaluation and management (E/M) services, when one coder is responsible for both facility and professional coding for the same encounter.

For example, when one coder is responsible for only facility coding of outpatient E/M services, Healthcare Common Procedure Coding System (HCPCS) Level II code G0463 is the only code that Medicare requires, and it has no specific clinical documentation requirements. 

However, when one coder is responsible for both facility and professional coding of outpatient E/M services, the coder also has to choose from over 10 Current Procedural Terminology® (CPT®) E/M codes for the professional coding, and there are documentation requirements regarding the following E/M elements:

• Complexity of the patient's medical problems
• Extent of patient data that was reviewed/analyzed
• Level of patient risk associated with the care provided/planned

When any of these three E/M elements are missing or poorly documented, the professional coding for the encounter might be delayed until a provider query can be written, communicated, and resolved.

Editor’s note: This Q&A was excerpted from our HIM Briefings newsletter.