Contempo Coding Podcast

Staying Ahead in Medical Billing: Insights with Pam Vanderbilt

• Victoria Moll • Season 2 • Episode 6

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Promised to be a treasure trove of information, today's episode invites you to navigate the intricate world of medical billing and coding alongside our esteemed guest, Pam Vanderbilt, owner of Knowledge Tree Billing. An industry veteran, Pam uncovers the layers of this dynamic field that's constantly evolving, emphasizing the essentiality of keeping abreast with the rapid changes in regulations and the transformative power of automation. As Pam so aptly puts it, it's not about cramming the answers, but it's about knowing where to search for them.

Navigating further, we tackle the compelling task of enhancing medical documentation and crystallize the significance of collaborative networking. The conversation meanders through the critical process of defining the medical necessity of a visit, crafting a narrative through notes, and circumventing provider burnout. We spotlight the balancing act between minimal medical documentation and reaching an exemplary level of detail.

Moving into the future, Pam shares her enriching experiences from various medical coding conferences and retreats while highlighting the importance of self-investment and forward planning. We uncover some unique benefits of attending retreats over conferences and the convenience of virtual learning and online resources. As we delve deeper into healthcare challenges, Pam shares her progression towards catering affordable education for healthcare providers, coders, and billers. So, buckle up for an enlightening journey through the complexities and future possibilities of medical coding and billing with Pam Vanderbilt.

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Speaker 1:

It's time for the Contempo Coding Podcast Discussions knowledge and insight to help you succeed in the medical coding industry. And now here's your host, victoria.

Speaker 2:

Hey everyone, welcome back to the channel. I am here today with Pam Vanderbilt. Pam is the owner of Knowledge Tree Billing, which is a full-service medical billing company that provides compliant revenue cycle consulting services and provider-owned practice education and services as well. So I knew Pam originally because she did a lot of writing for Namists. And then I saw her come to the Harrisburg chapter and I was speaking at the same chapter event at the same time and I'm like Pam, she's from Namists, she's so smart because she does all of that stuff for Namists. And Pam became a fan of the channel and had no idea that. I actually thought she was amazing because I knew her as this wonderful expert in E&M and I was like, oh, pam, we spoke at the same time. So thank you, pam, for coming on the channel.

Speaker 1:

Thank you so much for having me and I was definitely fan-girling by the few.

Speaker 2:

So, with so many years of experience in auditing and revenue cycle analysis, what are some of the big changes you've seen over the years? Some of the most significant ones in medical billing and coding.

Speaker 1:

I think there are a couple different directions that I could answer that question. Actually, I do feel like, in days gone by, you didn't necessarily need to be trained as a coder to work in the billing department, right, it should have been. Ideally, yes, but the rules have become so much more complex. The regulations are complex and, as we saw through COVID, they change and change rapidly, and so I think that that really is one of those. We have to be at the top of our game. We have to stay current in understanding what's happening as it relates to our specialty but not just our specialty our industry so that we make sure that we've got compliant documentation, we've got information going on on a clean claim and we know how to play the game on the back end if we get a denial, how to appropriately handle those denials Is it invalid denial or not?

Speaker 2:

Yeah.

Speaker 1:

And so there's been a lot of change and we have to stay really current.

Speaker 2:

And I think one of the things that we'll see more is we have all this automation that's up in Comeaia and it's been easy in the path to pull up one chart and look at it and go, yep, that's right, that's the codes. But when you're auditing the same provider and looking at notes and looking at a lot of repeat notes, that's when you start catching those sort of things. Absolutely oh, this provider's used the same macro for every single patient. This provider's used the same template for every single patient. This provider has copied forwarded the same note for this patient for the past 10 years.

Speaker 1:

Or, even better, the same note for this patient and every other portion they've ever seen for the last 10 years.

Speaker 2:

Yeah, so it's until you really take some of those deep dives and look at these things, when they can go undetected for like so long, absolutely. And then, of course, the practice wants to kick back and be like oh well, we've never had this problem before. We don't understand.

Speaker 1:

But right, well, and just because you haven't been audited yet, it just means you don't know that you were audited. Right, because I guarantee you in some way, shape or form you have, if you're getting those requests to send records pre-payment, you are being audited, you're being audited, yeah.

Speaker 2:

Yeah, yeah. So you have a lot of different credentials in the field, to the point that I think some of them you're just doing for fun at this point, right? Oh, absolutely.

Speaker 1:

You know, I, it's a guess.

Speaker 2:

So have these different areas of expertise auditing compliance, Do you have the practice management one yet you do. So how have all of those different areas and getting that expertise in those areas? How has it influenced your career?

Speaker 1:

I firmly believe that it really kind of has shaped my understanding that we don't live in silos. I think there are probably people out there that are coders and will always only be coders. But in general, if we understand how the business of healthcare happens, we have to understand how each piece works together in the puzzle. To what degree we need to understand that varies based on what we're doing.

Speaker 2:

I know this much of credentialing and provider enrollment and that's all I've ever needed to know. But I know that much of credentialing and provider enrollment.

Speaker 1:

I'm a few on that and what I do know is if it's not done right, we're in big, fat trouble and I can refer you to the right person to get it done right. Right, because that's the other thing. I may have all these credentials but I don't have to remember everything by myself. I have Victoria if I have a question about skin tag and plastics and all the reconstruction. I've got other people for other specialties, so I don't have to remember all the details. I have to know where to go for the resource if I need help.

Speaker 2:

Right. I think that's one of the things that I love the most about coding is it's not about memorizing all of the answers, it's about knowing where to go and find them. Absolutely, I don't know all the guidelines to sepsis off the top of my head. I could not recite them, I could not tell, but I know where to find them. That's when I'm looking at a chart and I'm like oh, patient septic, I know there's some kind of guideline on this. Let me refresh my memory of what that is. I know where it is in the guidelines.

Speaker 1:

Absolutely. That's one of the first things that I think I really learned as I was starting down a path into this side of the industry. I worked for someone who, if I had a question, she'd go start looking stuff up. I'm like what are you looking up? No, well, the answer is actually right here. Oh well, I could have done that. Why don't you just tell me to go look it up here? As we help each other learn how to fish, we start learning. Oh my gosh, all this information is out there for us. We just have to know how to go find it.

Speaker 2:

What is the right resource for it? Oh my gosh. Yes, I can't tell you how many people I've encountered that are like well. I found this on the AAPC forum, where Betty Sue posted five years ago that this is how she's always billed for this gynecological service. I'm like well, that might have been great five years ago in her region, but what does our region do?

Speaker 1:

right now. Right now, yes. Well, the other thing is that you have to be careful, because they sound like they know exactly what they're talking about, but they're actually giving very bad advice If you're on a forum, regardless of what forum it is, and they don't cite authoritative references that you can go and follow and do your own research. Don't take the word for it. Y'all. Don't take my word for anything. Go do your own research. I'm giving you the information that is current and to the best of my knowledge at the time, but it may not be right for your circumstance, right, right?

Speaker 2:

So you teach about documenting to the level that demonstrates the complexity of the work that the provider actually performed. Can you share some tips on how providers can achieve that?

Speaker 1:

I always go back to telling the story. We've had these fabulous changes in ENM. I am a huge supporter of the 2021 and updates to 23 guidelines because I feel like, if the providers understand truly what those changes are, that it's making their life easier, and so I teach them. Tell a story. Your chief complaint is the title of your story. Your history is your introduction to the visit yeah, how's the patient doing?

Speaker 1:

And then you've got your medically appropriate exam and any objective findings and then, when you get to your assessment and plan, that's when you really tell me, as the auditor, as the coder, as the insurance payer or as the patient, exactly what you know about taking care of the health of a patient. Don't just dump a diagnosis code in and refill medications How's the patient doing? Do we need to order more labs for this problem? What do we need to do? Wrap it up and give us a good conclusion and make it a really good one. And if it sounds like maybe I'm suggesting the soap notes kind of did that well and what we've done in EMR doesn't necessarily pick it up as well, I am saying that, but we have to use the tools that we have also, so make the best of the resources and the style of documenting that you have, but tell us a story.

Speaker 2:

Yeah, and I feel like sometimes we see two different extremes of that. We see we just pulled in the problem list, continue as you've been, you know. And then we see these providers that pull in everything from every nook and cranny of the medical record where it's the diseases that they've had anything for the past 10 years, and sometimes they just add on to whatever was last time and it's like I just need to know today what happened today. All right, kristi Paul.

Speaker 1:

Well, and that's that is true. And I think also I have quite a few clients who are primary care and so annually they're trying to capture their HCC and get that HCC risk out. And so you know, from a profi side of things, we teach you don't put a diagnosis on unless you're actually doing something. Is it a problem being addressed today? But there are purposes from a data perspective that they are trying to capture those diagnoses. Well then, capture your HCC diagnoses, not your signs and symptoms from something that's in the active problem list but actually as a resolved issue from 20 years ago. Right, right.

Speaker 2:

Yeah, you're not treating their UTI from two years ago during their annual wellness visit.

Speaker 1:

Yeah, I think one of the things that I try and teach providers, because I found that I'll look at a note sometimes and I'll be on the fence. I kind of think maybe this is a four, but what I'm seeing isn't getting me there. And so if I sit down with a provider and say, tell me what happened in the room with the patient this day, and they tell me the story, and I'm like, oh my God, it's a five, you missed it. Yeah, let's make sure that we get what you just told me into the next encounter. That's like this and they're like, but it's just so hard with the EMR and I have to point and click. Stop pointing, click it, stop copy paste, stop, carry forward. Hit your little microphone and do voice to text and dictate your notes, because you just told me a story that I can't see in your point and click, carry forward copy paste and macros.

Speaker 2:

Yeah, and it doesn't need to be. I mean, it's nice for us if it's in this nice little bulleted compact list, but it does have to be If it's easier for the provider and provider burnout is just. It's getting so bad, it's an issue. It is like to the point that I even said to some of my friends I'm like I'm at the point where I almost want to get concierge care because I can't get into my Pyrrhaea care physician for almost nothing. So, yeah, how can the physicians with their documentation and the auditors that are reviewing the services, how can they collaborate to make sure that the documentation is kind of supporting that level of medical necessity without causing that extra burden on the physician?

Speaker 1:

I find sometimes, when I'm talking to others in the industry, that we have this very defined idea. This is what the guidelines say and you have to put this here, yeah.

Speaker 2:

Knock it off.

Speaker 1:

Yeah, we should never have taught them you have to have 14 systems in the review of systems. If it wasn't relevant, don't do it right. We've got to stop being so black and white in what we're telling them and give them the concept and then allow them to run with it, and it is a collaboration. So then go back after they've run with it for a little bit and go okay, just a slight tweak. I don't need 10 paragraphs, but could you just Just give me a little tweak that better defines and shows the complexity? Because, remember, I'm not clinical and likelihood is, as the reviewer at the carrier is also non-clinical and oh, by the way, neither is your patient, and at the end of the day, the notes contained within the record belong to the patient.

Speaker 2:

Yeah, yeah, it's a big difference between, okay, what is minimally acceptable, what's the very least that you have to do, yes, and what is our pie in the sky, hope and dream of what we would love to see in your documentation. We have to find sort of the balance somewhere in between there.

Speaker 1:

Well and I even even before the changes in the guidelines, I would I'd be looking at providers sometimes and I'm not to call out any particular EMR, but there are some EMRs that are used on the facility side more predominantly that you will get a level one follow up hospital visit that is 25 pages long, because every stinking laboratory result and radiology result and everything else is in the note and I'm having to dig through all of that. Knock it off, quit putting stuff in your note that's not relevant to the note and if you put it in, tell me why it's there, explain the relevance. And if you got that part down, you're gonna make your life easier, you're gonna make my life easier and we're going to support the services and the payment for the services instead of ending up having to defend for that payment.

Speaker 2:

Yeah, volume doesn't always necessarily mean the higher level of service.

Speaker 1:

Volume means I'm probably going to down code you because I can't figure out what you really did. Yeah, exactly.

Speaker 2:

So networking has been a big part of your career and, like you talked about having those other resources that you can reach out to having people in your network, do you have any tips for networking for coders that are remote? Maybe they don't have budgets for like the big in person events.

Speaker 1:

I think there are a lot of opportunities. Clearly, we learned through COVID if we weren't already working in remote environments that we can connect remotely. I feel like I'm connecting with you, not in the same way each time I watch one of your videos, but on the flip side of that, we can zoom, we can FaceTime whatever we want and we're still having that face to face connection, real time audio video. But I do think that it's important, whether you're certified or not, be active in your local chapter. It's fabulous education, it's great opportunity. A lot of the meetings are still virtual, so maybe you're not face to face, but I know the chapters are making the effort to at least create a couple of opportunities a year for everybody to come together. Take advantage of it. Make it a priority. Schedule the day off of work if you have to Make it a priority because you've got to continue to build your network.

Speaker 1:

From the conference perspective, I highly recommend conferences. I think APC does a great conference. Namus is my favorite conference in the whole wide world. There's others. If you're in the billing arena, you've got AMBA out there. They do really good conferences, but they are, admittedly, expensive. We are not staying at Motel 8 this week right Right, I look so jealous.

Speaker 2:

There was some kind of healthcare compliance organization that had been slightly on my radar but I hadn't really been too intimately involved in. All of a sudden, my LinkedIn has flooded with these pictures of these people out into this conference in Anaheim. I'm like I could have gone out to a healthcare compliance seminar conference, met all of my friends and gone to Disneyland.

Speaker 1:

Absolutely. Yeah, and there are. You know other not everybody is cheeky boutique when it comes to their conferences and so, for example, advanced Coding Services has these fabulous retreats that they bring around the country. The goal is to have for a year San Diego Prescott one that's in South Georgia and New York. So there's somewhere that's drivable for a lot of people and they're meant to be more intimate. You would never expect 300 people there because then it loses the retreat.

Speaker 1:

This and it's literally. You know, you as the attendee and me as a speaker, and Christine Hall is both. You know we're. It's all of us there together and we're all on the same level, sharing and communicating. And Beth got on to me well, they can get on to me but pointed out that I never got out of my flip flops the whole time we were in San Diego, because it's just be comfortable. You don't have to get all dressed up and fruit through. We're there to learn and network. And if you can afford to be at every conference and if money is an issue, plan ahead, invest in yourself, pick one, you know. If your interest is really auditing and compliance, save up and go to the NamUs conference. If you want a more across the board with a heavy focus on coding. Go to an APC conference. If you want that more relaxed environment, more intimate and we're going to learn anything about practicing the business of medicine, then find a retreat. But save the money up, invest in yourself. Don't rely on your employer to invest in your education.

Speaker 2:

Yeah, I think that's where a lot of people get tripped up. They're like, oh, I want to do this, but my employer won't pay for it. Well, if you're looking to evolve, if you're looking to grow in your career, sometimes you have to make those sacrifices, and it has a lot to go to a conference. But when you have something that's drivable, like a regional conference or like a seminar, it makes it a little bit easier Absolutely. And in the absence of that, there's a lot of great virtual trainings that you can do as well. I'm excited to see the continued progress of Natasha Timberlake, how she's been out watching everything and now she's starting to speak. And I'm like, natasha, I'm waiting to see you at HealthCon as a speaker is what I'm waiting for Absolutely.

Speaker 1:

And because that's going to be the next step. Lady Martina, she's speaking for our chapter coming up and it will be her first live presentation. And what I'm excited to see for her is not just her presenting at an AAPC conference, but doing it bilingually, because there is a definite dearth of education on the coding and auditing front, because we don't have enough bilinguals in this country that are educating and hot tip if you speak at a conference, most of the time they let you in the conference for free.

Speaker 2:

Yeah, yeah, so that's a money saving tip. So how do you see the field of medical coding evolving in the future, especially with some of the intimidating new technology that we have going on?

Speaker 1:

It scares me a little bit. I'm going to be really honest with about it, not scared that I'm going to lose my job, that all of a sudden all of us are going to lose our jobs because the robot's going to come in and take over, but more concerned that, even as evolved as the technology has gotten, there is a uniqueness to the care of the health of patients that is very different than any other industry out there, and I think that there are nuances that that the AI is never going to be able to pick up. We could never train it.

Speaker 2:

I always used to laugh when I worked in these large organizations and they'd bring in all of these lean management people. Yes, and I would always hear from them. We always thought we had this down because manufacturing was so easy and all these other industries were just so good to go in and implement all of these lean management tactics. And then we tackled healthcare and the usual procedures were just not working. Like they just don't.

Speaker 1:

Well, and yes, it is a business and yes, ultimately you would like at least enough money coming in to keep the lights on for the business and keep a roof over your head and food in the mouth bellies of your family, right, but at the end of the day it is not like any other business.

Speaker 2:

But it's fascinating too to see things like Google and Amazon start getting into healthcare, and I think it's Amazon has I don't know if it's kind of like a limited telehealth sort of service that they have now, where you can go in and like scan your insurance card and set up like a virtual I don't know if it's a virtual video visit or just like I have a UTI and can you give me a prescription and here's what I'm doing in. Someone reviews it and they spit out what you need. But it's just it's so weird to like think about healthcare in the same spectrum of where I go to order office supplies and carpets.

Speaker 1:

Exactly yes, and it'll be interesting to see how those develop and progress. I think the other thing, though, that we have to keep in mind is who's providing those services, and, of course, let me let me just play devil's advocate for a second. Is it robots? Yeah, and playing devil's advocate for a second. There's so much opportunity for healthcare fraud out there, yeah. Is this legit or is this a compliance risk? And are we becoming a victim of the compliance risk?

Speaker 2:

Right, that was one of the questions that came up to me. I'm like ee, so what would be preventing someone from just, let's say, even me as example? I take my insurance card, I say I'm so and so, but I give my friend symptoms because she doesn't have insurance. So I can get her a prescription and I'm not really the person that I say. I am Like there's, is there, like what is? What is the barrier there? That's, who's stopping me from doing that?

Speaker 1:

Right, exactly so. And I just I think there's so many opportunities, kind of like these companies that reach out to these unsuspecting providers. They're usually single provider practices that are not super up to date on on the industry, compliance industry and like hey, can you just do these little televisits with these patients and give them a script for their DME or give them a script for their insulin, and then the provider goes down in the middle of a healthcare sting. Yeah, I'm totally unaware that they were doing something like that, you know.

Speaker 2:

So, yeah, yeah, it's it's, it's concerning, they're on our toes. They do Always something new to learn and watch out for.

Speaker 1:

And I don't think that all technology is bad, though no, I think there are. It should be a tool, though it should not be the end, all be all.

Speaker 2:

Yeah, I think some providers I've seen, especially some of the new residents, they're very adapt at it and, like I've seen some of the residents where they're like, well, I have macros, but I have like very customized ones and I have a blank space so that here's my one for my patients that have a diabetic complication, and then when I see my diabetes patients, I put in this macro and I fill in this part and this part. Oh, okay, well, since it's customized for the condition and not just everyone's getting the same thing like.

Speaker 2:

I can, I could see that, and you're very good at that?

Speaker 1:

Yeah, exactly. Well, and if you think about it, way back in the day, way back before we ever even considered electronic medical records, when we had transcriptionists, they used macros and you know the doctor would dictate normal exam, except yeah, and they would give the exceptions. And so the transcriptionist would bring in that normal template and then make the appropriate changes.

Speaker 2:

Yeah, which was I've actually shadowed in on providers where I watched them rounding on the inpatient floor, saw what they asked the patient, saw what they examined, watched them go out to the floor, pick up their dictation phone and then use their full normal exam template and four view systems and I'm like I was just in the room there with you and I knew the hell you didn't do that?

Speaker 1:

You did not do that. That's like I asked if my previous life, when I was in the ortho world, asked my providers. I'm like I noticed you do this GI exam on a majority of your patients and I am not clinical, so help me understand how that GI exam corresponds with what you're doing for their left toe complaint today and uniformly across the board I would get a dozen. It's just part of the template and I'm like did you do the exam? No, and I said okay, did you sign the note? Yes, that's fraud. Oh, I'm like you'll only document what you did. But I did have my hip specialist, appropriately, was doing a GI exam and explained to me clinically how it was relevant to what she was doing. Because there are areas in the abdomen, hip and pelvis you know that kind of your pain can be referred and is it musculoskeletal or is it GI? Was an appropriate concern? Okay, but I was like, okay, I can follow that I'm on board.

Speaker 2:

I like when they put in their templates that the rectal exam was deferred and it's like well, if I was coming in for an ear exam, I would also defer a rectal laser venation be done Exactly. I think we should take that out of the template. Perfect.

Speaker 1:

Are you sure? I'm quite sure.

Speaker 2:

So what's next for you in your career and with knowledge, tree billing? Do you have any kind of goals or plans that you're excited about?

Speaker 1:

I am super excited that we have seen growth from the billing company perspective. But we kind of stay in our niche and I like that smaller practice because those are typically the practices that don't have the wherewithal to have a certified coder. They don't have somebody in there with strong compliance knowledge and so we're not your typical billing company. We don't just claims out, post the payments, maybe we write it off or maybe we appeal it. We are looking at the entire revenue cycle and identifying where there are issues.

Speaker 1:

Do we not understand what an insurance card means when we look at who the insurance is? How do we train the front desk? Do we need to go in and kind of do a little bit of focus training with the providers and kind of help get them moving along? Do they need a compliance plan? Do I need to contact Sean Weiss and say, sean, I need to come in and do a gap analysis? So it's kind of we aren't their billing company, we are their billing department and so they have that resource like a larger organization would have. But I can't just do that. I love teaching, I love the research that goes behind it and understanding the why's, and so my goal is to move the company along in a direction that I'm not necessarily in the day-to-day billing part of it as much as I'm creating opportunities for affordable education for people all across the country, and so that's my ultimate goal.

Speaker 2:

So for healthcare providers, for coders, for billers or just all of those people, all of them, that's cool. So like in-person or online education, both.

Speaker 1:

Both, but online. I'm not a huge fan myself of on-demand education. I like the interaction. I think that as the learner you get more out of it and that partially it's just my own personality. But as a trainer, as an educator, I like that interaction as well. So I see that most of what I would do is or what I do even now is live, but I will do it online or in-person.

Speaker 2:

Great Well, thank you so much, Pam, for connecting with me today and for agreeing to come on the channel and be part of the video podcast. Where can my viewers find you? Is there somewhere they should connect with you in your business? Absolutely, on LinkedIn. Okay, great Well. Thank you so much, Pam. I appreciate it. Thank you, I appreciate it. Thank you as well.