Teach the basics of practice management to medical students

For three years before I applied to medical school, I worked in post-Katrina New Orleans helping to rebuild school-based health centers. One of the main challenges, however, was how to create a sustainable safety net for at-risk youth to whom we were hoping to provide much needed health services — key word being “sustainable.”

All too often, there isn’t funding to carry out primary care’s mission of improving the health of communities and underserved populations. At the time, I was a public health manager, and I often felt frustrated at physicians who couldn’t optimize their coding and billing. Not only were they leaving money on the table for the much-needed services they were providing, but they also made my job of trying to advocate for them near impossible.

One of the avenues we tried to pursue was state funds to support the school-based health centers, but without proper coding, we never had accurate data to show exactly the needs we were addressing. In addition, when we asked state legislators for increased funding, we were easily countered with, “But you don’t use the money we’re giving you now through Medicaid …” The only thing I could do was stare back like a greedy kid who asks for seconds before I’ve finished what’s already on my plate.

At the time, I didn’t understand why it was so difficult for physicians to code for the services they provide. It is part of their job. I remember thinking, “What is wrong with you people?! Don’t they teach you how to do your job in medical school or residency?”

Now that I’ve been through medical school and part of residency, I realize that actually no, no one teaches us how to actually be functioning physicians in the community. We learn about medicine, a necessary part of being a good doctor but not the only part. We seem to forget that physicians operate in a larger health care system that is increasingly scrutinized for its cost and quality. It is more than just knowing how to diagnose and treat diseases anymore.

In the changing health care environment, physicians are going to be expected to code accurately to prove we’ve met certain quality measures and to justify our billing. Let’s not forget that one of Medicare’s major cost-saving strategies is to cut down on fraud. Coding inaccurately, whether intentional or not, could then be considered fraud. And as there’s increasing pressure to drive down costs, we can no longer afford to leave money on the table if we want to be sustainable — particularly when working with underserved populations.

It’s a deficit in our medical education system that we don’t teach the basics of practice management to medical students and residents and then expect them to graduate from residency and suddenly know how to run a practice. In this past year I’ve been promoting the importance of understanding coding and billing within my own program by giving lectures about coding and billing, creating note templates for our electronic medical record that provide interactive coding education, and developing coding cheat sheets for other residents. I hope that by raising awareness, students and residents can continue to learn more throughout our training, and ultimately graduate more prepared to be functional physicians in the community.

Raymond Tsai is a family medicine resident who blogs at Primary Care Progress.

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  • Ava Marie Wensko George

    Loved your discussion about coding, but you missed a very big point…..You can’t code blind. You must have ICD-10 ready clinical documentation in order to code correctly and not be charged with fraud in the inpatient setting. You also must have the same level of specificity and granularity in clinical documentation in the outpatient setting even though the codes that are used in outpatient are from a different code set. In healthcare today we are looking for a consistency between elements of the SOAP note and all inpatient documentation. Unfortunately, students, residents, interns, and fellows are not taught how to document the patient clinical encounter to correctly capture the patient’s medical story. I would like to see this intensely taught at all levels of learning from med school throughout residency. I spend a lot of my time helping physicians understand why they cannot document urosepsis without supporting clinical indicators of a generalized sepsis present. Physicians must describe the clinical condition of the patient including fever or hypothermia, tachypenia, tachycardia, oliguria, hypotension, metabolic acidosis (elevated lactate level, anion gap, or reduced blood pH), acute onset of confusion associated with the disease process (altered mental status), shock, positive blood culture including organism. The term urosepsis is no longer a billable code.

    Keep up the good work~

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