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Communicate With Confidence to Physicians:

Coding as a Second Language

Written by:Dr. Joseph J. Sivak MD and Ms. Lorraine J. Sivak

Communicate with Confidence Copyright © AAPC 2009

DISCLAIMER

This course was current at the time it was published. This course was prepared as a tool to

assist the participant in effective communication. Although every reasonable effort has been

made to assure the accuracy of the information within these pages the ultimate responsibility

for clear communication and the correct submission of claims or response to any remittance

advice lies with the provider of services. The American Academy of Professional Coders (AAPC)

employees, agents, and staff make no representation, warranty or guarantee that this

compilation of information is error-free and will bear no responsibility, or liability for the

results or consequences of the use of this course. This guide is a general summary that

explains commonly accepted aspects of effective communication but it is not a legal or medical

document. All information is intended for general knowledge only and is not a substitute for

medical advice or treatment for specific medical conditions. We cannot and do not give medical

including mental health advice.

NOTICES

Current Procedural Terminology (CPT®) is copyright © 2008 American Medical Association. All

Rights Reserved. CPT® is a registered trademark of the American Medical Association (AMA).

COMMUNICATE WITH CONFIDENCE TO PHYSICIANS:CODING AS A SECOND LANGUAGE

Written by:Dr. Joseph J. Sivak MD and Ms. Lorraine J. Sivak

Editorial contributions by:Stephanie L. Jones, CPC, CEMC


Contents

FORWARD ..............................................................................................................................................................4

INTRODUCTION ....................................................................................................................................................5

CODER-SELF-AWARENESS ................................................................................................................................6

Exercise One: Locus of Control. ...................................................................................................................6

Exercise Two: Styles of Communication ......................................................................................................9

Exercise Three: Learning and Personality Styles .......................................................................................16

THE MIND OF A PHYSICIAN ............................................................................................................................21

Stereotypical Physician Personalities .........................................................................................................21

Appreciating Physician Development ........................................................................................................22

Understanding How a Physician Thinks .....................................................................................................22

THE CODER-PHYSICIAN WORKING ALLIANCE ................................................................................................23

Top 10 Coder Mantras for a Successful Coder-Physician Working Alliance ............................................23

Communication that “Works” .....................................................................................................................24

CONCLUSION ......................................................................................................................................................30


FORWARD

Physician coding education is vital to payment-compliant medical

documentation and proper reimbursement. Often the delivery of this

information falls to the coder, who is responsible for correctly coding per the

medical record while also leaving no payable, rendered service unreported.

Coders are required to explain detailed coding models, which require a solid

understanding of medical terminology and anatomy that often does not equal

the physician’s.

Compounding the issue, the personality and style of varied physicians may

cause some coders to fear communicating unpopular coding concepts:

- What if I mispronounce that medical term?

- What if she erupts and I sit there speechless?

- What if he does not find me creditable?

- What if I am asked a question and I do not know the answer?

- What if I am unable to get my point across?

Level of education, experience, and talent aside — the best coders and billers

have also mastered the art of communicating with physicians in ways that

almost always produce positive results. A certified professional coder is one of

the physician’s best tools in proper reimbursement, and is often an important

key to the financial success of the medical practice.

This course addresses persuasive communication skills necessary to manage

challenging situations with physicians and turn them into a catalyst for positive

change. A key to effective communication is in understanding your own

unconscious motivations and needs. For this reason it will begin with a Self

Assessment. The remainder of the course is designed to help a coder better

understand and respond to physicians with the end goal being…

Flawless documentation that promotes proper payment for all rendered

services!


INTRODUCTION

Communication between a

professional coder and a

physician are vital to the

correct payment process. When

a provider understands the

rules around documentation,

coding and compliance are

optimized. To make the best

business decisions a physician

needs clear and trusted

communication from the

coders who are helping to assure his or her proper payment. Sometimes the

lines of communication are muddied by frustrations making communication

more difficult. No one likes to be told there are rules when those rules result in

lowered income or being told that services are worth less than expected. This

communication barrier between a coder and a physician can be overcome by

three Cornerstones of Effective Coder Communication.

Cornerstones for Effective Coder Communication

¸ CODER-SELF-AWARENESS

¸ UNDERSTANDING THE MIND OF A PHYSICIAN

¸ THE CODER-PHYSICIAN WORKING ALLIANCE

It may not be possible to convince someone that the sky is blue if they believe it

is purple. Challenging the beliefs of a person can result in lost communication

because one or both parties feel the other is arrogant, ignorant or both. The

real question is:

How important is the color of the sky if the story is about birds in flight?

“To effectively communicate we must

realize that we are all different in the

way we perceive the world and use this

understanding as a guide to our

communication with others.”

~ Anthony Robbins


CODER-SELF-AWARENESS

The ability to see beyond communication obstacles and focus on desired

actions or outcomes begins with a complete understanding of your own

strengths and weaknesses. Increasing your awareness to your natural listening

and response styles enables you to better modify responses, if need be, for

best results. This is the first step in effective communication.

The following self assessment exercises will give you a good point of personal

perspective.

Exercise One: Locus of Control. Based on J.B. Rotter (1966) Generalized

expectancies for internal versus external control of reinforcement Psychological

Monographs 80 (1 Whole No. 609).

Answer the questions below truthfully as possible. Check the box A. ˛ or B. ˛

according to the statement you most agree with:

A B Question

A. People's misfortunes result from the mistakes they make.

B. Many of the sad things in people's lives are partly due to bad luck

A. One of the major reasons why we have wars is because people

don't take enough interest in politics.

B. There will always be wars no matter how hard people try to prevent

them.

A. In the long run people get the respect they deserve in this world.

B. Unfortunately an individual's worth often passes unrecognized no

matter how hard he tries.

A. The idea that Physicians are unfair to Coders is nonsense.

B. Most Coders don't realize the extent to which their credibility is


influenced by accidental happenings.

A. Capable people who fail to become leaders have not taken

advantage of their opportunities.

B. Without the right breaks one cannot be an effective leader.

A. People who can't get others to like them don't understand how to

get along with others.

B. No matter how hard you try some people just don't like you.

A. Trusting to fate has never turned out as well for me as making a

decision to take a definite course of action.

B. I have often found that what is going to happen will happen.

A. In the case of the well prepared Coder there is rarely if ever such a

thing as an unfair test of their coding ability.

B. Many times coding tends to be so unrelated to billing that accuracy

is really next to impossible.

A. Becoming a success is a matter of hard work; luck has little or

nothing to do with it.

B. Getting a good job depends mainly on being in the right place at

the right time.

A. The average citizen can have an influence in government decisions.

B. This world is run by the few people in power and there is not much

the little guy can do about it.

A. When I make plans I am almost certain that I can make them work.

B. It is not always wise to plan too far ahead because many things

turn out to be a matter of luck anyway.

A. In my case getting what I want has little or nothing to do with luck.

B. Many times we might just as well decide what to do by flipping a

coin.

A. What happens to me is my own doing.

B. Sometimes I feel that I don't have enough control over the direction

my life is taking.


SCORING LOCUS OF CONTROL

For each question that you answered “B” please add one point. Scores range

from 0-13.

0 1 2 3 4 5 6 7 8 9 10 11 12 13

Internal locus of control External locus of control

What does the Locus of Control mean?

Locus of Control refers to an individual's beliefs regarding main causes of

events in life.

Internal Locus of Control

“Luck” is when opportunity

meets preparation. I create

my own luck because I

work to generate

opportunity and prepare

myself for it.

External Locus of Control

“Fate” and forces outside

of my control have direct

power over what happens

to me. You can’t control

luck.

Rotter (1966) believed that those who have an Internal locus of control

(Internals) were more likely to work for goals and effectively manage delays in

achieving them by keeping the end goal in mind. They are better able to adjust

their behavior to influence improved performance.

Internal locus of control External locus of control


More Likely to… More Likely to…

• Tolerate vague situations

• Learn from their mistakes

• Prefer games based on skill

• Prefer “Black and White” rules

• Suffer from depression

• Prefer games based on chance

Studies show that Internals tend to be less “stressed out” because they control

their choices and their circumstances. Those with an external locus of control

feel more at the mercy of outside events and have less (or no) control over their

situation. Because Internals tend to be healthier and happier the following tips

can help those with external tendencies feel better about daily situations,

including communicating effectively with those around them.

“Life is 1% what happens to you and 99% how you choose to feel aboutit.”

When you feel caught up in frustrating situations in your life, surprise yourself

with the number of options you have:

• Write down every option open to you in your current situation.• Even if you don’t like the choices available, remember that you have

choices• Evaluate your list and decide on the best course of action to meet your

goals• Practice expanding your mind to all open possibilities• Replace “I HAVE to…” or “I NEED to…” with “I CHOSE to…”

Exercise Two: Styles of Communication

There are four generally recognized communication styles that influence every

message we attempt to convey. They are “Assertive,” “Aggressive,” “Passive”

and “Passive-Aggressive.” The following exercise can help you to determine

your prominent style.

Statement True orFalse

1 If you get your own way it is by chance or so it seems.

2 You tend towards indirectness with the air of being direct.

3 You end up in many situations where you must stand up for yourself andothers must be put in their place by you.


4 Others view you with respect, trust, and know where you stand.

5 You’ll participate in a win-lose situation only if you are pretty sure youwill win.

6 You feel anxious, ignored, helpless, manipulated and angry at yourselfand/or others.

7 You manipulate others to choose your way.

8 You feel confident, self-respecting, goal-oriented, and valued.

9 You demand your own way.

10 You allow others to choose and make decisions for you.

11 The outcome is that others achieve their goals at your expense. Yourrights are violated.

12 Others feel confused and frustrated; not sure who you are, what you standfor, or what to expect next.

13 You convert win-lose situations to win-win ones.

14 You are often derogatory towards others.

15 The best defense is a good offense.

16 Others feel guilty or superior and frustrated with you.

17 If you don’t get your way you’ll make snide comments or pout .

18 It is not important for you to "put others in their place" or be derogatory.

19 Others often feel humiliated, defensive, resentful, and hurt around you.

20 You are self-serving but not straight forward about it.

21 You choose and make decisions for you.

22 The outcome is determined by above-board negotiation. Your rights andothers are respected.

23 Others view you in the exchange as angry, vengeful, distrustful, andfearful.

24 Your underlying belief is that you need to fight to be heard and respected.If that means you need to manipulate by passive or aggressive ---so beit.

25 You feel righteous superior and vindicated frequently. Sometimes you feelguilty later.


26 You are emotionally dishonest.

27 Your underlying belief is that you should never make someoneuncomfortable or displeased except yourself.

28 Others view you in the exchange as someone they need to protectthemselves from. They fear being manipulated and controlled.

29 You are willing to compromise and negotiate.

30 You are "brutally" honest and most likely pride yourself on this.

31 You are indirect and self-denying.

32 You quietly work hard to please others, you avoid "stepping on toes" butthen become resentful and feel taken for granted

33 You feel confused and unclear on how to feel. You’re angry but not surewhy.

34 You are self-respecting, self expressive and straight forward.

35 You are not only direct but also forceful.

36 Your underlying belief system is that you have to put others down toprotect yourself.

37 You generally try to avoid conflict.

38 In win-lose situations you will make the opponent look bad or manipulateit so you win.

39 You are sensitive and caring with your honesty.

40 Your underlying belief is that you have a responsibility to protect yourown rights.


SCORING STYLES OF COMMUNICATION

The below table references each of the 40 questions you have just answered.

For each question that you answered “True” place an X in the shaded box. If you

answered “False,” leave the box blank. Do not enter anything in non-shaded

boxes.

1 2 3 4 56789

101112131415161718192021222324252627


28293031323334353637383940

Sum of“X”

TotalsAGGRESSIVE ASSERTIVE PASSIVE

PASSIVE-AGGRESSIVE

What Does a Communication Style Mean?

Assertive Communication is the relating of thoughts, ideas and feelings in a direct

manner to others without having to be “right.” It is an honest approach that respects

all parties involved. An assertive communicator understands that it is important to

declare their position without creating anxiety in others. They express feelings

truthfully and comfortably. They practice the concept of: Your ideas are “ok” and my

ideas are “ok” - perhaps different, but equally important. Assertive communication is

straightforward, sincere, and self-important without being hurtful to others.

Everyone’s rights are important.

• Actively engaged in the situation

• Self assured

• Truthful

• Handles problems “head on”

• Able to separate emotions from the problem

• Values the personal rights of self and group

• Values the collective intelligence of the group


Aggressive Communication is the relating of thoughts, ideas, and feelings in an

indirect manner to others while having to be “right.” It often incorporates the use of

antagonistic language, including name-calling and mockery. Aggressive

communication is insincere and self-important without regard to being hurtful to

others. Only the aggressor’s rights are important.

• Emotionally engaged in the situation - Angry when faced by problems

• Antagonistic

• Argumentative about opinion

• Self serving

• Demands personal rights

• Does not believe in a collective intelligence

Passive Communication is the act of not relating thoughts, ideas and feelings to

avoid dealing with direct confrontation. The passive communicator’s rights are

personally forfeited because they think that they do not have the right to an opinion or

they are not strong enough to assert one.

• Intentionally disengaged from the situation

• Unworthy

• Unconfident

• Avoids problems

• Forfeits personal rights

• Does not feel part of the collective intelligence

Passive-Aggressive Communication is the relating of thoughts, ideas, and

feelings in an indirect manner to others in order to be proven “right.” Like the Passive

communicator, Passive Aggressive communicators often say nothing to protect their

rights while employing less obvious Aggressive communication to demand those rights

returned to them. They often show resentment in non-verbal ways (i.e. procrastination,

pouting, complaining, and blaming others). Only the Passive Aggressor’s rights are

important, but they are taken in a roundabout way.

• Seems unengaged in the situation

• Calculating

• Self serving

• Demands personal rights by “showing” someone they are wrong

• Deals with problems in a roundabout manner

• Conniving

• Elects to side-line the collective intelligence


What does this mean about me?

Very few people are all one or another style. Communication styles cannot

usually be based on one snap shot self assessment. A cumulative and honest

look at typical responses will help you to better recognize natural patterns. It is

not important to label a personality type as “bad” or “good.”

For example:

Aggressive style can work when:

• a quick decision has to be made• an emergency is happening• being right is crucial to an important fact• evoking a sense of competition on a team

Passive style can work when:

• the issue is inconsequential• the conflict will not change an outcome already in progress• the boss is not right - but is still the boss• the differing core belief has no impact on your own (i.e.: religion)

Passive Aggressive style can work when:

• a decision needs to be delayed• it makes sense to wait until tempers cool down


Exercise Three: Learning and Personality Styles

Rank each of the following statements. For each question labeled A-D, choose

“Most” if the statement is very much like you and “Least” if the statement is not

like you at all. Do not skip rows.

Ranking: Most 4, Some 3, Less 2, Least1

Rely on logical thinking and facts. a

Am personally involved. b

Can look for new patterns through trial anderror.

c

To learn I:

Use hands-on activities and practicalapplications.

d

Dependable, accurate, logical, and objective. a

Understanding, loyal, cooperative, andharmonious.

b

Imaginative, flexible, open-minded, andcreative.

c

When at my best I amcalled:

Confident, assertive, practical, and result-oriented.

d

Are factual and to the point. a

Show appreciation and are friendly. b

Encourage creativity and flexibility. c

I best respond to bosseswho:

Expect me to be involved be active and getresults.

d

Objectivity and correctness. a

Consensus and harmony. b

Originality and risk taking. c

With a group I value:

Efficient and results. d

Informed, serious, and accurate. a

Supportive, appreciative, and friendly. b

Creative, unique, and idealistic. c

People I am mostcomfortable with are:

Productive, realistic, and dependable. d

Methodical, efficient, trustworthy, andaccurate.

a

Cooperative, genuine, gentle, and modest. b

As a rule I am:

High-spirited, spontaneous, easily bored ,anddramatic.

c


Straightforward, conservative, responsible. d

Collection of acts to determine the rightsolution.

a

Finding the solution that will please othersand me.

b

Brainstorming creative solutions that feelright.

c

When decision-making Ibelieve in:

Quickly choosing the most practical andrealistic solution.

d

Analytical. a

Caring. b

Innovative. c

In one word I am:

Productive. d

Reaching accurate and logical solutions. a

Being cooperative and respecting people’sfeelings.

b

Finding hidden connections and creativeoutcomes.

c

I "shine" when:

Making realistic practical and timely decisions. d

Gathering technical information and beingobjective.

a

Making personal connections and working ingroups.

b

Exploring possibilities creative tasks beingflexible.

c

When learning new thingsI like:

Producing results solving problems andmaking decision.

d

Sum of a:

Sum of b:

Sum of c:

Sum of d:

Derived from: Sharon K. Ferrett Ph.D Peak Performance: Success in College and Beyond

Your predominant style correlates with the greater sum of choice a, b, c, or

d.

A= Analyzer

B = Supporter

C= Creator


D= Director

Learning and Personality Styles indicate your preference in working with others

in making decisions and in learning new information. Understanding your own

preference and the preferences of others can be most valuable in improving the

likelihood of effective communication.

Point to Ponder: Moving beyond your personal Learning and Personality Styles

what style does your physician display?


Analyzers: “Let me examine that working.”

Common Traits Communication with Physician

Analyzers often requires Coders to:

• Careful

• Commonsensical

• Detached

• Detailed-Oriented

• Exact

• Hesitant

• Methodical

• Restricted

• Sudden

• Undemonstrative

• Unimaginative

• Use facts

• Show the source document on

rules

• Use rationales

• Be organized detached and calm

• Be professionally impersonal

• State facts concisely

Supporters: “ Why does that work?”


Supporters often requires Coders to:

• Easy going

• Faithful

• Helpful

• Kind

• Naïve

• Passive

• Sensitive

• Slower acting

• Sympathetic

• Tactful

• Thankful

• Be genuine

• Be personable

• Be pleasant

• Create a calm environment

• Create familiarity

• Focus on personal values

• Listen with caring


Creators: “ What if it worked like ….this?”


Creators often requires Coders to:

• Artistic

• Contradictory

• Disjointed

• Eager

• Imaginative

• Impractical

• Intolerant

• Original

• Pioneering

• Romantic

• Spontaneous

• Undependable

• Be engaged

• Be excited

• Be flexible

• Embrace change

• Focus on imaginative ideas

• Talk about potential

Directors: “I have taken that apart to see how it works.”


Directors often requires Coders to:

• Antagonistic

• Controlling

• Dynamic

• In charge

• Overwhelming

• Persistent

• Results driven

• Self-assured

• Self-confident

• Focus on accomplishment

• Focus on outcome

• Forfeit control

• Make no excuses

• Set milestones and timelines

• Take responsibility


THE MIND OF A PHYSICIAN

Stereotypical Physician Personalities

In addition to academic strength,

physicians have been required to

demonstrate a commitment to improving

the human condition. The work of

physicians typically requires long,

irregular hours; more than one-third of

full-time physicians worked 60 hours or

more a week in 2006. Because acceptance

to medical school is highly competitive

and the education and training requirements are among the most demanding of

any occupation, many physicians share an appreciation for life-long learning

and thrive on challenge.

It is not possible to definitively categorize a physician’s personality based solely

on an area of practice. There are commonalities that may attract certain

personality types to certain areas of study and practice. Results are relative

from one specialty to another and may include:

Anesthesiologists

• Dominating

• Extraverted

• Less sociable

• Skeptical

• Vigilant

Family Practitioners

• Agreeable

• Altruistic

• Imaginative

• Rule conscious

• Trusting

Internists

• Introverted

• Organized

• Persistent

• Self-reliant

Gynecologists

• Goal oriented

• Conscientious

• Persistent

• Scrupulous

• Sympathetic

• Trusting

General Surgeons

• Curious

• Decisive

• Dominant

• Opinionated

• Unemotional

• Need variety

• Social

Pediatricians

• Agreeable

• Easy Going

• Extraverted

• Less conscientious

• Pleasant

Psychiatry

• Dominant

• Tolerant

• Egotistical

• Less sociable

• Abstract thinker

• Tender-hearted

“In comparison with internists, surgeonsare thought to be more aggressive, rigid,insensitive, impersonal, hostile,extroverted, explosive, more energetic andambitious.”

- THE SURGICAL PERSONALITY: A COMPARISON OF

MEDICAL AND SURGICAL RESIDENTS WITH THE

RORSCHACH, Stanley H. King, Ph.D., Charles G.

McArthur, Ph.D., and John C. Norman, M.D.


Derived from: Borges NJ Osman WR . 2000 J Vocational Behavior 58: 22-35 Borges NJ Savickas MI. 2002 J Career

Assessment 10: 362-380

Appreciating Physician Development

In order to better understand and communicate with physicians, coders must

appreciate the dedication, sacrifice and time spent in their professional

development.

Figure 1: Time Line to becoming a physician

2008 2023

2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023

2008 - 2012

Under -Grad

2012 - 2015

Medical School

2019 - 2020

Fellowship

2016 - 2023

Residency

2019

License to Practice

Becoming a physician requires a “character of commitment” in order to

complete a lengthy training period where sacrifice is demanded on several

levels:

• Physical

• Emotional

• Psychological

• Spiritual

• Financial

When communicating with a physician, it is important to consider that during

indoctrination to medical training and the Hippocratic Oath, the primary focus

was on the “ patient above all else .” Little or no mention of coding is made,

perhaps because coding is about being paid – which is a magical, mythical, and

far-off concept to the average medical student.

Understanding How a Physician Thinks

A doctor is taught to assume responsibility for peoples’ lives and to make

constant decisions with the goal of best patient outcomes foremost at all times.


The mind of a physician constantly classifies information; prioritizing,

reclassifying and reprioritizing in an effort to make the best decision -- often

under extreme intellectual pressure. Doctors often don’t see coding as having

an effect on the patient outcome, making it almost always classified as a very

low priority in everyday existence. Physicians often believe there is no margin

for error in caring for their patients; all patients expect perfection, which

physicians strive for. Many are already under a greater than average level of

stress - before a coder drops the following bomb:

“Doc--Your total effort may never be paid.”

Ouch!

For many physicians, learning that no matter how hard they work, how hard

they try, how much effort they have given for the patient may not correlate with

the coding and payment is difficult. This can lead to a barriers in the coder-

physician working relationship and translate to communication problems if the

coder is unaware of the conflict. The personality style of the physician may

cause him or her to react to a coder in an unpleasant manner. A coder must

remember that a physician is not there to build or tear down the coder’s self-

esteem, and usually has no actual investment in doing either. At different

times, a physician will not always consider or recognize the work of a coder as a

major priority. It should not represent a blow to a coder’s personal self-esteem.

It is never about you, unless YOU make it about you!

THE CODER-PHYSICIAN WORKING ALLIANCE

Top 10 Coder Mantras for a Successful Coder-Physician Working

Alliance

1. I know my job and prepare myself with the facts in all coding situations.

2. My confidence is based on my choice to feel confident. I am confident.

3. I know my personality strengths/weakness. I temper my delivery and

response.

4. Coding is healthcare business and is not “personal.” I don’t get my

feelings hurt.

5. Physicians are often overworked. I ask for their time wisely.


6. I make coding rules easy for physicians so their focus stays on patient

care.

7. Physicians don’t have time to see what I do. I self-start & do not need

praise.

8. I am pleasant, calm and in control of my feelings. No one can “make” me

upset.

9. Asking a question does not undermine my value. When I don’t know I

ask.

10. I understand the personality of my physician. I use it to create

positive conversation.*

*Analyzer

I state facts conciselyand use manyreference materialsfrom respectedsources. I show thingsin an organized,formal way.

*Supporter

I use analogies andexplain the benefitassociated with eachissue. I amparticularly careful toempathize on pointsof frustration.

*Creator

I show all the correctvarious ways to dothings. I point outwhere the problemsare and the typicalways to fix them. Iask for feedback.

*Director

I provide allsupportingdocumentation andsuggest a direction. Ifocus on positiveresults of correctcoding while I do notattempt to justify therule’sappropriateness.

Communication that “Works”

Body Language

Communication is not just words: a lot of communication comes through non-

verbal communication.

• 7 percent of communication happens in spoken words.

• 38 percent of communication happens through voice tone.

• 55 percent of communication happens via general body language.

Mehrabian, Albert, and Ferris, Susan R. “Inference of Attitudes from Nonverbal Communication in Two Channels,”

Journal of Consulting Psychology, Vol. 31, No. 3, June 1967, pp. 248-258

Mehrabian, A. (1971). Silent messages, Wadsworth, California: Belmont

Mehrabian, A. (1972). Nonverbal communication. Aldine-Atherton, Illinois: Chicago


Controlling your body language can help to ensure effective communication.

There is some study to suggest that mimicking the body stance and pose of the

person you are conversing with may subconsciously put them at ease. Example:

If you notice that the physician is sitting with legs crossed, resting elbows on

the table with head resting on palms, you may try sitting across the table with

legs crossed, elbows on table and arms flat or folded on the table. If you notice

that the physician is standing with hands on hips you may try doing the same.

As a note of caution, it is important to not make an overt gesture or to

unnaturally position your body because this may have a reverse affect - making

you appear manipulative or insincere, or at least: uncomfortable. The following

body language mistakes to avoid are:

• Arms crossed: You are defensive.

• Constant eye contact: You are aggressive.

• Fidgeting: You are bored or impatient

• Hunched Posture: You lack confidence.

• Little eye contact: You have low interest or lack confidence.

• Rubbing your nose or mouth: You are lying.

• Tapping: You are impatient or nervous.

• Touching your face or hair: You are timid.

• Watching the time: You are anxious to move on to something else.

Tips for tricky communication situations:

Verbal Attack:

The key to bridging this gap is to not accelerate the situation. Breathe.

Remember that it is rarely YOU being yelled at, it is the situation. Do not allow

yourself to become upset, you have a choice to steer the conversation in a

better direction or to make it worse! If a physician is upset and angry, yelling

may be their learned method of reacting to these emotions –their way of

“letting it out.” Empathizing with someone like this can help move the direction

of the conversation to a move positive arena.

• “I understand that you are upset.”

• “I’d want to yell too if I worked as hard as you do and this was happening

to me.”

• “This is an upsetting situation for you. I’m sorry you feel this way.”


• “I know this is distressing. Would you prefer to have this conversation

later?”

Note: Do not allow yourself to become verbally abused. In some situations your

best reaction is no reaction and ending the conversation.

- “What you have to say is important to me, but I can’t hear past your

yelling. I feel afraid. May we continue this later when you feel less angry?”

Sometimes, this honest response is enough to sober the situation immediately.

If not, it will often set the stage for a better conversation in the future.


Defusing Verbal Attacks:

Listen. Whenever you are verbally attacked let the physician know that you arenot going to fight them and that you are trying to understand how they arefeeling.

Example:Physician – “You can’t be serious! This is too a CONSULTATION! Howon earth can you tell me otherwise?”

Less Effective Coder Response – “Let me tell you why it is! A consultrequires….”

Effective Coder Response – “Tell me why you feel this way. I’minterested in your thought process on this.”

Don’t need to hear you are “right.” Some people have a natural inclination towant to “win” if an argument arises. If you find yourself in a confrontation,remember that any “counterattack” you launch serves only your ego. It isunlikely that you will often hear the words: “You are right.” Reactingemotionally will not change the situation or help you achieve your goal from theconversation.


Less Effective Coder Response – “Well, it IS wrong. It is FRAUD if youkeep marking these visits as consults.”

Effective Coder Response – “I agree with you that it is confusing.Sometime the verbiage used in reimbursement rules is very differentfrom how the same term is used clinically. Let me show you how tocode these so that you can bill for a consultation every time thecoding rules allow it.”

Have thick skin. A simple and effective method to diffuse a verbal attack is topay no attention to it. By showing no response, the likelihood of continuance isdiminished.

Example:


Physician – “You are ridiculous! This is a consultation!”

Less Effective Coder Response – “I am not ridiculous! Your coding isincorrect.”

Effective Coder Response – “Unfortunately the rules on billingconsultations can seem a bit ridiculous. Let me show you the rulehere in the book…”

Be Kind. One of the most powerful tactics for defusing an aggressor is a sincere“I’m sorry.” This is not always easy to do when you are being confronted oversomething that is not directly your doing.

Example:Physician – “You can’t be serious! This is too a CONSULTATION! Howon earth can you tell me otherwise?”Less Effective Coder Response – “I didn’t make the rules! I just followthem.”

Effective Coder Response – “I’m sorry this is confusing. Iunderstand why you feel this way.”

Agree. It is very difficult to continue yelling at something when they use threesimple words: “You are right.”


Less Effective Coder Response – “You are not correct on this, Dr.”

Effective Coder Response – “I agree with you. The coding rules aredifferent from clinical rules; what do you suggest we do to keep youout of harm’s way? ”

Give away “control.” Physicians are trained to be in complete control duringcrisis situations. It is a difficult thing to feel as if they have no control. It can behelpful to re-word statements from absolutes to phases that put them incontrol of their own actions.

Example:Physician – “You can’t be serious! This is too a CONSULTATION!How on earth can you tell me otherwise?”


Less Effective Coder Response – “This is the way that it is. You haveto do it this way.”

Effective Coder Response – “You can keep yourself out of harm’sway if you want to and code according to rules or we couldchallenge the rules if you would like to. Would you suggest that wewrite a letter to the medical association about this or to theinsurance companies we contract with?”

Divert Negativity. Redistributing the tension between you and the physician canallow the physician to place the “blame” elsewhere, which allows you to moreeffectively come to mutual resolution and agreement.


Less Effective Coder Response – “I am telling you the right way to dothis.”

Effective Coder Response – “The people who make these rules mustnever have practiced the art of medicine! They make us comply withthem, though. The good news is that I think I can explain this so thatyou confidently bill for a consultation every time they will allow it.”

Initiating a difficult conversation:

The following steps are a good guide to follow when initialing a conversation

that you believe will not be received favorably.

- Ask. Is this is a good time to talk?

- Be direct. Prepare a short statement in advance that gets right to thepoint.

- Be quiet and listen. Allow the physician to respond completely, even ifdefensively.

- Sympathize. Try to understand the physician’s perspective and makeeffort to show it.

- Empathize. Express that you realize how hard this is; that it is hard foryou too.


- Assess. Is the physician is ready for you to expand on your openingstatement?

1. A sincere (“Tell me more”), non-angry question (“How can you saythat?”)

2. Ask: Are you ready for me to expand on this? No: wait. Yes:continue

- Commence the conversation with detail. Explain the rationale, reward,and risk.

CONCLUSION

Level of education, experience and talent aside — the best coders and billers

have also mastered the art of communicating with physicians in ways that

almost always produce positive results. Your physician needs coders. Your

performance is often an important key to the financial success of the medical

practice. The purpose this course has been to provide the framework for

persuasive communication skills that allow a coder manage challenging

situations with physicians and turn them into a catalyst for positive change.

From understanding yourself, to understanding the physician, the coder can

communicate coding concepts that are, for many physicians, a foreign language

- with confidence.

About the Authors:

Lorraine J. Sivak has over twenty four years of experience as a medical coder.

She is the former AAPC Local Chapter President of the Ft Lauderdale chapter

and currently manages her husband’s outpatient psychiatric practice in Duluth,

Minnesota.

Dr. Joseph J. Sivak MD is a board certified General Psychiatrist with seventeen

years experience treating patients. He is an assistant professor at the University

of Minnesota at Duluth College of Pharmacy and School of Medicine and

currently operates a psychiatric outpatient practice in the Twin Ports area of

Duluth and Superior WI.

1/15/2009

1

Communicate With Confidence to Physicians:

Coding as a Second Language

Add Presenter Name Here

Agenda

9:00 – 10: 45 am

Lecture and Coder Self Assessment

10:45 – 11: 00 am

Break

11:00 – 12:00 pm

Lecture and Group Exercises

Communication Cornerstones

Effective Communication between a coder and a physician:

Coder-Self-Awareness What can I learn about me? Locus of Control Style of Communication Learning and Personality Style

Understanding the Mind Of a Physician Typical personality The making-of a physician Why a physician thinks as he/she does

The Coder-physician Working Alliance Mantras for success Communication that WORKS

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2

Coder-Self-Awareness

Understanding your strengths and weaknesses.

Increased awareness:

Of natural listening and response styles

Ability to see beyond communication obstacles

Modify responses as needed for the desired results

Coder-Self-Awareness: Locus of Control

Turn to the Locus of Control Worksheet in your workshop book.

!10 minutes. Please read each question carefully.

Choose A. or B. for each question.

Chose your answer by your first impression.

Do not “over think” the questions.

Locus of Control: Self Assessment

For each question you answered “B” give yourself one point.

0 1 2 3 4 5 6 7 8 9 10 11 12 13

Internal Locus of Control

“Luck” is when opportunity

meets preparation. I create

my own luck because I work

to generate opportunity and

prepare myself for it.

External Locus of Control

“Fate” and forces outside of

my control have direct power

over what happens to me.

You can’t control luck.

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Locus of Control: What does it mean?

Internal locus of control

More Likely to…

External locus of control

More Likely to…

• Tolerate vague situations • Prefer “Black & White” rules

• Learn from their mistakes

• Prefer games based on skill

• Suffer from depression

• Prefer games based on chance

Internalizing the External Locus of Control

Life is 1% what happens to you & 99% how you

choose to feel about it.

Write down every option in your current situation.

Even if you don’t like the choices, remember you have them

Decide on the best course of action to meet your goals y g

Practice expanding your mind to all open possibilities

Replace “I HAVE to…” or “I NEED to…” with: “I CHOSE to…”

Coder-Self-Awareness: Style of Communication

Turn to the Styles of Communication Worksheet in your workshop book.


Choose True or False for each question.



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Style of Communication: Self Assessment

For each question that is True place an “X” in the shaded

box on the row that correlates with the number of the question.

If you answered False leave the row blank.

Count the number of “X” marks you have in each column.

The column with the largest number is your dominant Style of Communication

Sum of

“X”

Totals

5AGGRESSIVE

7ASSERTIVE

2PASSIVE

1PASSIVE!AGGRESSIVE

What does this assessment mean?

Very few people are all one or another style.

Communication styles cannot be based on one self assessment.

A cumulative look and awareness allow a person to better recognize natural patterns of communication.

Let’s take a closer Look…

Communication Style: Assertive

Assertive Communication is the relating of thoughts,

ideas and feelings in a direct manner to others without

having to be “right”. I’m ok. You’re ok.

Actively engaged in the situation

Self assured

Truthful

Handles problems “head on”

Able to separate emotions from the problem

Values the personal rights of self and group

Values the collective intelligence of the group

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Aggressive Communication is the relating of thoughts, ideas and feelings in an indirect manner to others while having to be “right”. Only the aggressor’s rights are important.

Emotionally engaged in the situation

Antagonistic

Communication Style: Aggressive

g

Argumentative about opinion

Self serving

Demands personal rights

Does not believe in a collective intelligence

Communication Style: Passive

Passive Communication is the act of not relating

thoughts, ideas and feelings to avoid dealing with direct

confrontation. The passive communicator’s rights are

personally forfeited.

Intentionally disengaged from the situation

Unworthy

Unconfident

Avoids problems

Forfeits personal rights

Does not feel part of the collective intelligence

Passive-Aggressive Communication is the relating of

thoughts, ideas and feelings in an indirect manner to others

in order to be proven “right”. Only the Passive Aggressor’s

rights are important, but they are taken in a roundabout

way.

Communication Style: Passive!Aggressive

Seems unengaged in the situation

Calculating

Self serving

Demands rights by “showing” someone else wrong

Deals with problems in a roundabout manner

Conniving

Elects to side-line the collective intelligence

1/15/2009

6

Styles: Not "Good" or "Bad"

Aggressive style can work when:

a quick decision has to be made

an emergency is happening

being right is crucial to an important fact

evoking a sense of competition on a team

Passive style can work when:

the issue is inconsequential

the conflict will not change an outcome already in progress

the boss is not right---but is still the boss

the differing core belief has no impact on your own (i.e.: religion)

Passive Aggressive style can work when:

a decision needs to be delayed

it makes sense to wait until tempers cool down

Coder-Self-Awareness: Learning and Personality Styles

Turn to the Learning and Personality Styles Worksheet in your workshop book.


Choose “4- Most” if the statement is very much like you. y y

Choose “1- Least” if the statement is not like you at all.

Do not skip rows.



Add together the total sum for each “a” choice, each “b” choice, each “c” choice and each “d” choice.

Your predominant style correlates with the greater sum

of choice a, b, c, or d.

Learning and Personality Style: Self Assessment

A= Analyzer

B = Supporter

C= Creator

D= Director

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What does this assessment mean?

Very few people are all one or another style.

Very few people are equally all styles.

Personality styles cannot be based on one self y yassessment.

A cumulative look and awareness allow a person to better recognize natural personality traits.

Let’s take a closer Look…

Analyzers:

“Let me examine that working.”

Common Traits Physician Analyzers require Coders to:

Careful

Commonsensical

Detached

Detailed-Oriented

Use facts

Show the source document on rules

Use rationales

Be organized detached and calm Detailed Oriented

Exact

Hesitant

Methodical

Restricted

Sudden

Undemonstrative

Unimaginative

Be organized detached and calm

Be professionally impersonal

State facts concisely

Supporters:

“Why does that work?”

Common Traits Physician Supporters requires coders to:

Easy going

Faithful

Helpful

Be genuine

Be personable

Be pleasant

Kind

Naïve

Passive

Sensitive

Slower acting

Sympathetic

Tactful

Thankful

Create a calm environment

Create familiarity

Focus on personal values

Listen with caring

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Creators:

“What if it worked like ….this?”

Common Traits Physician Creators require Coders to:

Artistic

Contradictory

Disjointed

Eager

I i ti

Be engaged

Be excited

Be flexible

Embrace change

F i i ti id Imaginative

Impractical

Intolerant

Original

Pioneering

Romantic

Spontaneous

Undependable

Focus on imaginative ideas

Talk about potential

Directors:

“I have taken that apart to see how it works.”

Common Traits Physician Directors require Coders to:

Antagonistic

Controlling

Dynamic

In charge

Focus on accomplishment

Focus on outcome

Forfeit control

Make no excusesg

Overwhelming

Persistent

Results driven

Self-assured

Self-confident

Set milestones and timelines

Take responsibility

The Mind of a Physician

Committed to improving the human condition

Typically work long, irregular hours

More than 1/3 of full-time physicians work 60+ hours a week

Training is among the most demanding of any occupation

Appreciate life-long learning

D t t “ h t f it t” h Demonstrates a “character of commitment” wheresacrifice is demanded on several levels:

Physical

Emotional

Psychological

Spiritual

Financial

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Sterotypical Personality Traits

Anesthesiologists

Dominating

Extraverted

Less sociable

Skeptical

Vigilant

Family Practitioners

Agreeable

Gynecologists

Goal oriented

Conscientious

Persistent

Scrupulous

Sympathetic

Trusting

Pediatricians

Agreeable

Easy Going

Extraverted

Less conscientious

Pleasant

Psychiatry

Important note: It is not possible to categorize a personality based solely on an area of practice.

Altruistic

Imaginative

Rule conscious

Trusting

Internists

Introverted

Organized

Persistent

Self-reliant

General Surgeons

Curious

Decisive

Dominant

Opinionated

Unemotional

Need variety

Social

y y

Dominant

Tolerant

Egotistical

Less sociable

Abstract thinker

Tender-hearted

• Derived from: Borges NJ Osman WR . 2000 J Vocational Behavior 58: 22-35 Borges NJ Savickas MI. 2002 J Career Assessment 10: 362-380

Patient Above All Else (…even coding)

I swear by Apollo, Asclepius, Hygieia, and Panacea, and I take to witness all the gods, all the goddesses, to keep according

to my ability and my judgment, the following Oath.

To consider dear to me, as my parents, him who taught me this art; to live in common with him and, if necessary, to share my goods with him; To look upon his children as my own brothers, to teach them this art.

I will prescribe regimens for the good of my patients according to my ability and my judgment and never do harm to anyone.

I will not give a lethal drug to anyone if I am asked, nor will I advise such a plan; and similarly I will not give a woman a pessary to cause an abortion.

B t I ill pr r th p rit f lif nd rtBut I will preserve the purity of my life and my arts.

I will not cut for stone, even for patients in whom the disease is manifest; I will leave this operation to be performed by practitioners, specialists in this art.

In every house where I come I will enter only for the good of my patients, keeping myself far from all intentional ill-doing andall seduction and especially from the pleasures of love with women or with men, be they free or slaves.

All that may come to my knowledge in the exercise of my profession or in daily commerce with men, which ought not to be spread abroad, I will keep secret and will never reveal.

If I keep this oath faithfully, may I enjoy my life and practice my art, respected by all men and in all times; but if I swerve from it or violate it, may the reverse be my lot.

- HIPPOCRATIC OATH- HIPPOCRATES- FATHER OF MEDICINE, c460-c367 b.c. Greek Physician

Physican Development

High school and Undergrad: needs outstanding grades to get accepted for further training

70-90% of those in pre-med will not be accepted to medical school and will change career gpaths

Medical School: Financial sacrifice becomes apparent, still secondary to the commitment

Must memorize, process and integrate thousands of facts and concepts every 4-6 weeks

Typically none of those facts or concepts involve coding

Typically there is no orientation to the coding process in medical or pre-medical education

Medical school:

Average student financial debt in 2007 was $139,517

75.5% of students graduate with debt of at least $100,000

87.6% of graduating students have outstanding loans

1/15/2009

10

“Pssst….Doc--Your total effort may never be paid.”

Doctors don’t see coding as having an effect on the patient outcome, making it classified as a very low priority

Learning that no matter how hard they work, how hard they try, how much effort they have given for the patient may not correlate with coding and payment is difficultmay not correlate with coding and payment is difficult.

This can lead to a barriers in the coder-physician working relationship

Top 10 Coder Mantras for a Successful Coder Physician

Working Alliance

I know my job and prepare myself with the facts in all coding situations.

My confidence is based on my choice to feel confident. I am confident.

I know my personality strengths/weakness. I temper my delivery and response.

Coding is healthcare business and is not “personal”. I don’t get my feelings hurt.

Physicians are often overworked. I ask for their time wisely.

I make coding rules easy for physicians so their focus stays on patient care. I make coding rules easy for physicians so their focus stays on patient care.

Physicians don’t have time to see what I do. I self-start & do not need praise.

I am pleasant, calm and in control of my feelings. No one can “make” me upset.

Asking a question does not undermine my value. When I don’t know I ask.

I understand the personality of my physician. I use it to create positive conversation.*

Personality and Positive Communication

I understand the personality of my physician. I use it to create positive conversation.

*Analyzer

I state facts concisely and

usemany reference

*Supporter

I use analogies and

explain the benefit

*Creator

I show all the correct

various ways to do things

*Director

I provide all supporting

documentation anduse many reference

materials from respected

sources. I show things in

an organized, formal way.

explain the benefit

associated with each

issue. I am particularly

careful to empathize on

points of frustration.

various ways to do things

and I point out where the

problems are and the

typical ways to fix them.

I ask for feedback.

documentation and

suggest a direction. I

focus on positive results

of correct coding and do

not attempt to justify the

rule’s appropriateness.

1/15/2009

11

Body Language

Communication is not just words

7% of communication happens in spoken words.

38% of communication happens through voice tone.

55% of communication happens via general body language.

“There is something about you I like…”

Mimicking the body stance of a person may subconsciously put them at ease

Physician is sitting with legs crossed, resting elbows on the table with head resting on palms, you may try sitting across the table with legs crossed, elbows on table and arms flat or folded on the table.

Physician is standing with hands on hips you may try doing the same.

Must not feel or look unnatural or it may appear insincere

Body Language Mistakes

Arms crossed: You are defensive.

Constant eye contact: You are aggressive.

Fidgeting: You are bored or impatient

Hunched Posture: You lack confidence.

Little eye contact: You have low interest or lack confidence.

R bbi th Y l i Rubbing your nose or mouth: You are lying.

Tapping: You are impatient or nervous.

Touching your face or hair: You are timid.

Watching the time: You are anxious to move on to something else.

Verbal Attack

Words to soften the situation: “I understand that you are upset”

“I’d want to yell too if I worked as hard as you do and this was happening to me”

“This is an upsetting situation for you. I’m sorry you feel this way.”

“I know this is distressing. Would you prefer to have this conversation later?”

Do not allow yourself to become verbally abused.

In some situations your best reaction is no reaction and ending the conversation.

“What you have to say is important to me, but I can’t hear past your yelling. I feel afraid. May we continue this later when you feel less angry?”

1/15/2009

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Defusing Verbal Attacks

Listen. Whenever you are verbally attacked let the physician know that you are

not going to fight them and that you are trying to understand how they are feeling.

Physician – “You can’t be serious! This is too a CONSULTATION! How on earth can you tell me otherwise?” y

Less Effective Coder Response – “Let me tell you why it is! A consult requires….”

Effective Coder Response – “Tell me why you feel this way. I’m interested in your thought process on this.”


Don’t need to hear you are “right”. Some people have a natural inclination to want to “win” if an argument

arises. If you find yourself in a confrontation, remember that any “counterattack” serves only your ego.


Less Effective Coder Response – “Well, it IS wrong for coding. It is FRAUD if you keep marking these visits as consults.”

Effective Coder Response – “I agree with you that it is confusing. Sometime the verbiage used in reimbursement rules is very different from how the same term is used clinically. Let me show you how to code these so that you can bill for a consultation every time the coding rules allow it.”


Have thick skin. A simple and effective method to diffuse a verbal attack is to pay no

attention to it. By showing no response, the likelihood of continuance is diminished.

Physician – “You are ridiculous! This is a consultation!”

Less Effective Coder Response – “I am not ridiculous! Your coding is incorrect.”

Effective Coder Response – “Unfortunately the rules on billing consultations seem a bit ridiculous until you go over them completely. Let me show you…”

1/15/2009

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Be Kind. One of the most powerful tactics for defusing an aggressor is a sincere

“I’m sorry.” This is not always easy to do when you are being confronted over something that is not directly your doing.


Less Effective Coder Response – “I didn’t make the rules! I just follow them.”

Effective Coder Response – “I’m sorry this is confusing. I understand why you feel this way.”


Agree. It is very difficult to continue yelling at something when they use three

simple words: “You are right.”

Physician – “You can’t be serious! This is too a CONSULTATION! How on earth can you tell me otherwise?”

Less Effective Coder Response – “You are not correct on this, Dr.”

Effective Coder Response – “I agree with you. The coding rules are different from clinical rules; what do you suggest we do to keep you out of harm’s way? ”


Give away “control”. Physicians are trained to be in complete control during crisis situations. It

is a difficult thing to feel as if they have no control. It can be helpful to re-word statements from absolutes to phases that put them in control of their own actions.

Physician – “You can’t be serious! This is too a CONSULTATION! How on earth can you tell me otherwise?”

Less Effective Coder Response – “This is the way that it is. You have to do it this way.”

Effective Coder Response – “You can keep yourself out of harm’s way if you want to and code according to rules or we could challenge the rules if you would like to. Would you suggest that we write a letter to the medical association about this or to the insurance companies we contract with?”

1/15/2009

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Divert Negativity. Deflecting the tension between you and the physician can allow the

physician to place the “blame” elsewhere, which allows you to more effectively come to mutual resolution and agreement.

Physician – “You can’t be serious! This is too a CONSULTATION! How on earth can you tell me otherwise?”y

Less Effective Coder Response – “I am telling you the right way to do this.”

Effective Coder Response – “The people who make these rules must never have practiced the art of medicine! They make us comply with them, though. The good news is that I think I can explain this so that you confidently bill for a consultation every time they will allow it.”

Initiating a Difficult Conversation Ask. Is this is a good time to talk?

Be direct. Prepare a short statement in advance that gets to the point.

Be quiet and listen. Allow the physician to respond completely.

Sympathize. Try to understand the physician’s perspective and show it.

Empathize. Express you realize how hard this is; it’s hard for you too.

Assess. Is the physician is ready for you to expand on your statement?

A sincere question (i.e. “Tell me more.”)

Not an angry question (i.e. “How can you say that!?”)

“Dr., are you ready for me to expand on this”? No: wait. Yes: continue

Commence the conversation with detail Rationale reward and risk

Group Exercises

Using scenarios presented, come up with a best response.

Remember: Conversation Initiation

Respect the physician's time

Be Direct

Sympathize/Empathize

Remember: Defusing Verbal Attack

Listen Listen

Don’t need to be right

Have thick skin

Be Kind

Agree

Give away “control”

Divert Negativity

We will present suggestions and discuss the results for each.

1/15/2009

15

Group Exercise One

Turn to the person next to you Consider together the following:

! 5 minutes.

The Coder performs an Audit of E/M codes. This audit finds the

Physician consistently under documents the medical decision

making of his exam. After the audit the Coder would like to show

the Physician what he has done wrong and “set him straight”.

What approach may be most successful?

Conversation Initiation

Is this is a good time to talk?

I’ve found a problem that could result in a payer under-coding your claims

Session Discussion: Exercise One

under-coding your claims.

I know that documentation rules are time consuming, but I want you to be paid properly for your work.

Listen.

“Tell me why you feel this way. I’m interested in your thought process on this.”

Don’t need to be right.

“You are right. This is confusing and makes no clinical sense.”

Have thick skin.

“It is ridiculous but we need to make sure you are fully & correctly paid.”

Be Kind.

“I’m sorry this is confusing. I understand why you feel this way.”

Session Discussion: Exercise One

y g y y y

Agree.

“I agree with you. What do you suggest we do to keep you out of harm’s way? ”

Give away “control”.

“We could write a letter to the Plan’s medical director about this.”

Divert Negativity.

“The payer must not understand how hard you work!”

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Turn to your partner Consider together the following:

! 5 minutes.

The Coder is reviewing an operative report in a specialty she has

f S ff

Group Exercise Two

never coded before. She is having a difficult time understanding

the procedure. The Coder would like to ask the Physician to

explain the procedure, but she doesn’t want to look bad. This is

a busy surgeon’s office and the Physician is always in a hurry. He

seems to hate to slow down and answer questions.




I have researched this but don’t fully understand what you did. I want you to be paid properly could you walk me through it so that I can code everything you did?

Session Discussion: Exercise Two

that I can code everything you did?

I know you are busy but explain this to me once I can make sure you get properly paid.

Listen.

“Tell me when a better time is for you?”


“I wish I knew this. I don’t want to guess with your $”

Have thick skin.

“Your payment is more important to be than my embarrassment over asking.”

Be Kind.

“I’m sorry that I am taking your time. I understand why you feel this way.”

Session Discussion: Exercise Two

y g y y y y

Agree.

“I agree with you. I need to know this. ”


“I could leave my code book with you to review and highlight.”

Divert Negativity.

“If coding school taught more surgical anatomy and med school taught more coding we would both be happier!”

1/15/2009

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! 5 minutes. The Coder is auditing records for an office to understand why

every E/M code with a -25 modifier is being denied. He finds that

the Physician documents “patient returns to the office today to

Group Exercise Three

the Physician documents patient returns to the office today to

receive injection.” Clearly each patient is coming in with the intent

of receiving the injection and it appears from the documentation

this Physician is abusively billing the insurance companies. He

has to tell the Physician that this is incorrect and she can no

longer bill this way. You confront the Physician about her use of

this modifier and she says “the last biller told me to do this at

every visit.” I’m just following the rules.


Session Discussion: Exercise Three



You have been given bad advice. We’ll need to modify things a bit to keep you out of harm’s way.

It must be frustrating to hear different things from different people. It is hard to know what to trust.

Session Discussion: Exercise Three Listen.

“I’d like to hear more about what you were told.”


“You are right. All coders should say and do the same thing.”

Have thick skin.

“I’d yell too if I were you. I can show you the correct way to do this.”

Be Kind.

“I’m sorry that you have been misled.” y y

Agree.

“I agree with you. You should never have to waste your time or effort. ”


“Would you like to read the official rules? Perhaps you’ll see something we could use.”

Divert Negativity.

“I am sure the previous coder was just trying to get you paid. She must not have realized how dangerous it was for you.”

1/15/2009

18


! 5 minutes.

While with the patient, the physician documents only brief

C

Group Exercise Four

statements. He uses a short hand that system the Coder has

never seen before. He usually goes back and documents the full

record at the end of the day but sometimes does not get back to

the record for several days or even a week. The compliance

department is concerned that the documentation is not timely

enough and has asked the coder to make sure services are

documented fully.


Session Discussion: Exercise Four



The your method of documenting may cause us to under code your services.

I know you are very busy and this is not your highest priority. I don’t want to see you get unpaid.

Session Discussion: Exercise Four Listen.

“I’m interested in your short hand system. Will you tell me more about it?”


“You are right. Documentation is time consuming.”

Have thick skin.

“I understand you are frustrated. Let’s talk about documentation short-cuts that code well for busy physicians.

Be Kind.

“I’m sorry that you have so few free moments in your day.”

Agree.

“I agree with you. You should only have to concentrate on patient care. ”


“Will you recommend a solution that will work better.”

Divert Negativity.

“I wish our compliance department could fully appreciate how hard this is for you.”

1/15/2009

19


! 5 minutes.

A new biller entered charges incorrectly, which resulted in many

C

Group Exercise Five

more denials than usual. The Coder usually enters charges and is

responsible. She also loads the system with the fee schedule and

contract rates. She needs to tell the physician why revenue is

down this month and tell him that new rates will cause him a 6%

cut this year.


Session Discussion: Exercise Five



Payment is going to be delayed on $1500 this month and there are changes in the fee schedule that I need to warn you of.

You are working harder than ever and I know this is the last thing you want to hear.

Session Discussion: Exercise Five Listen.

“It helps me to hear your thoughts on this.”


“You are right. You are working harder for less money.”

Have thick skin.

“It is important that I prevent mistakes and help prepare for changes.”

Be Kind.

“I’m sorry that your patient care is not more properly rewarded ” I m sorry that your patient care is not more properly rewarded.

Agree.

“I agree with you. Billing mistakes are not allowable. ”


“Would you like to see a financial forecast?”

Divert Negativity.

“I can’t believe that they are cutting payment like this and expect good physicians to stay in practice.”

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