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Professional Coders: 6 Lessons Learned from March Madness

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Today marks the first official day of March Madness. Basketball fans rejoice!

Brackets are still intact – the Cinderella of the ball has yet to emerge – buzzer beater upsets leave us asking from more.

Not surprisingly, the game of basketball is also a great metaphor for the revenue cycle:

1. Learn and master the fundamentals of the game.

Every basketball player learns the fundamentals of the game (passing, defense, dribbling, and shooting). They practice, practice, practice – honing their skills until they master them. Professional coders learn the basics including: medical terminology, anatomy, pharmacology, how-to translate narrative of the patient chart into procedure/diagnosis codes (CPT, HCPCS, ICD-10-CM, ICD-10-PCS), and published payer policies (ex: medical necessity, frequency, and bundling).  

According to Judy Sturgeon, CCS, the clinical coding/reimbursement compliance manager at Houston’s Harris County Hospital District, a common minimum standard to evaluate a coder’s efficacy is to achieve 90% to 95% accuracy for diagnosis-related groups (DRGs), with 95% being a reasonable “high” expectation for Medicare and Medicaid claims.

Like elite basketball players, it takes dedication, hard work, and the right attitude to achieve mastery of professional medical coding. Successful coders become masters when they understand and accept things will change and there's always something to learn. 

2. Be prepared both mentally and physically.

It's important to stay mentally and physically fit, especially in a high-stress environment like medical billing and coding. At times professionals coders can feel overwhelmed and emotionally drained when consistently coding high-stress specialties like oncology, ER/trauma, and pediatric surgery claims. Remembering to take breaks and step away can be both refreshing and reduce job-related stress.

Coding sometimes involves repetitive tasks, that exhaust even the most veteran coders. However, just like at the end of a game a tired player knows he needs to stay focused because the most mundane free throw could either send them home or propel them to the next round.

Whether you're a coder or a NCAA basketball player, remembering to give your brain time off to recover and practicing will help you take your game to the next level. It's equally important to be prepared mentally and physically. Practice constant mindfulness when coding to increase accuracy and productivity.

3. Be unselfish and a team player.


There's no "i" in "team," as the saying goes – the revenue cycle team should function the same way. Clinical staff (doctors, nurses, etc.) working together with the revenue cycle team (billers and coders) to figure out why claims are denied and what can be done to eliminate them. Most healthcare organizations operate in an "us” versus “them" environment, pitting the clinical staff against the medical billing and coding professionals.

The famous basketball quote, "There's no limit to what can be accomplished when nobody cares who gets credit" applies both on the court and in the hospital. It reminds us that the clinical staff and revenue cycle team can accomplish so much more when they work together and become one team, striving for the healthcare organizations goals. The revenue cycle is part of patient care – when both teams work well together – better patient care and patient satisfaction is achieved.

4. Be alert and aware. Anticipate the play.

The best basketball players are known for having amazing court vision and awareness. They know exactly where everyone is on the court, they anticipate their defender’s next move and are ready for anything. The more aware everyone on the revenue cycle team is of the entire RCM process from pre-registration to payment, the easier it is for anyone to step up and respond to a new challenge. 

Being reactive is bad for basketball and professional coders – waiting for denial responses to make a corrective action is wasting valuable time and resources for your healthcare organization. Working denials are like turnovers in basketball, they're avoidable – add up quickly and could end up costing you the game.

5. If the plays aren't working, re-adjust your game plan.

Medicare and commercial insurance rules are constantly changing. If claims are being denied, it may be time to adjust your strategy. Great coaches understand you have to monitor the tempo and be willing to adjust their game plan, and then adjust some more depending on the results.

Eliminating denied claims takes an innovative approach. It's our personal recommendation to pick your top 5 denial categories (ex: medical necessity, bundling, billing excessive units,, etc.), identify any trends, and and create a plan for improvement.  For example, medical necessity denials could be reduced by identifying the most commonly denied codes and by providing feedback to the clinical staff about the importance of making sure all symptoms are added to the chart. Accurate documentation from the clinical staff and coding for symptoms, not assumptions, can drive denials down.

Healthcare organizations can implement a "zone defense" to eliminate denials: tracking denials by specialty instead of by individual provider. Your first approach to eliminating denials might not be a slam dunk – keep trying new things and track your progress.

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6. Never give up. Persevere.

Professional coders accept all the challenges that come along with their role and continue to persevere – their flexibility, awareness, and willingness to work within limitations are just a few reasons. Coders who possess a "never give up" attitude, can be a game changer for the revenue cycle. Just think, fixing a single claim with the wrong DX code or modifier – might not seem like a lot – but fix the root cause and you'll enjoy the increased revenue that comes from filing a clean claim.