Considering the Relationship Between Coding, Compliance, and Patient Communication

Hi, my name is Grace Torres-Hodges. I am a podiatrist in Pensacola, Florida along the Gulf Coast, and I've been in practice for 22 years in a solo private practice. I did my undergrad at Vanderbilt, but I did my med school at the New York College of Podiatric Medicine Residency in St. Vincent's Medical Center. And like I said, in private practice for the last 22 years.

When thinking about issues like coding and compliance, one usually doesn't make a connection to the doctor-patient relationship. How do they connect and what does this mean in your practice?

So to me, the first thing to think about is what is the doctor patient relationship? Remember why you went into medicine. The essence of clinical medicine is that relationship that you have of helping another individual. And it goes beyond all the know, like and trust factors because people are entrusting you with their health or entrusting their loved one, usually a family member, with their health. And that's very humbling when you get that. And however, as you're practicing, you never want to forget about that. But healthcare, the way it's rendered today in insurance-based model, the health insurance networks are actually the ones that are dictating the relationship first. Because many times patients don't find you because of it being you.

One of the questions that always gets asked, are they in my network? And so the insurance networks are already kind of like a default meetup for you, and that little change doesn't seem like a lot. It may not have seemed like a lot back in the eighties when the networks were all coming into fruition, but now come to 2023, that's the norm. But what you have to remember is healthcare is what we render when we treat patients. It doesn't equal health insurance yet. The two terms get conflated all the time. And when you start talking about doctor, patient relationship and coding and compliance, they're really two different things. But because a lot of people are on using their health insurance networks in order to receive healthcare, the two get mixed together. Again, they're not the same thing. And ironically, traditional insurance-based medicine actually controls that doctor-patient, and they're now also controlling the way you render that care. And so the intermixing of both of those things, that's how I see they're connected.

What are some of the examples you feel clinicians can encounter in this area?

So what you have to remember is that a patient comes in and your first and foremost goal is to treat that patient. I'm going to use some, there's some examples in podiatry that are like classic, which make you realize something's up and what's going on. First off, why in the world do you need to have a prior authorization on a prescription that you write that you know the patient in front of you, but some third party is going to be the one that's going to say, okay, we need you to have this. Your patient can only get this prescription. You know what works for them? So prior authorizations that can sometimes mix up things and you have to have the right code many times, and you have to comply with the right protocol of failed treatments before you actually can prescribe it.

Let's talk about bilateral ingrown toenails. Patient comes in, a kid comes in with two toenails. Many insurance companies will not pay you for that second procedure on the other foot unless you've coded properly or bring the patient back. Again, from the patient's perspective, have you helped them if they're still in pain or they still have something going on over there? And then another example, I call it diagnosis discrimination. And what it is, is say for example, you have, we know all of us know about the diabetic foot and the diabetic shoe program and all the criteria needed in order to check the boxes properly in order for shoes to be covered. DME wise, what about the rheumatoid patient that has the gnarly foot with the extreme over overlapping hammer toes or the non-diabetic Charcot foot that can't fit in a regular shoe? Many of those patients, you'll find that they have a hard time getting their shoes covered, and we won't even go into wound care because if you want for wound care, many times if you preempt it and actually debride something rather than going through the protocol of slow wound care dressings, you might be able to speed up the process, but that's not how insurance wants us to do it.

So those are just some of the clinical challenges because in the end, you always want your patient to have the best. You always put yourself in their role. Again, getting back to that Doctor-patient relationship.

What one thing do you feel clinicians can do or focus on in their practices to improve in this area?

When it comes to coding and compliance, education is probably the number one thing to do, not just for you, but also to your patients because we're all in this healthcare together.

One of the things that's really odd that people don't realize and many doctors don't realize is that ICD when it was first initiated by the who, the World Health Organization was never meant to be used for financial criteria. It was never meant to be used for insurance. It was always used for monitoring disease states around the world. It was just to note that. So communication of history of stuff like that, communication with your patients, I always take the approach of explaining the clinical care that needs to be rendered. Then we worry about whether or not it falls within coding and compliance. Now, in some instances, based on the contract that you have with your insurance company, you may have to swallow some of the costs on that because your ethics are a little bit compromised when you don't follow their protocol for coding and compliance.

But you want what's best for your patient. It's a personal decision. For me, one of the ways that I found a way to improve coding and compliance is not work in that system. And so I work in what's called a third party free direct pay direct care model. I didn't change the way I practiced medicine, I just changed how I interacted with the system and I don't deal with it. So all the coding and compliance, I never liked it when I was in it. I was in it for 15 years. I've been out of it now for the last seven, and it's not for everyone. But that's the way I chose. And I think if you keep that in mind, the history of why we do coding, the education of just yourself and also to your patients of what's going on there, staying up to date on all of it, or finding alternative means to get out of it, I think that's how you can handle it.