Ep #46: The New NP’s Guide to Billing and Coding with Erica D the NP

Welcome to Becoming a Stress-Free Nurse Practitioner, a show for new NPs and students that want to pass their board exam the first time and make that transition from RN to NP as seamless as possible. I’m your host Sarah Michelle. Now, let’s dive into today’s episode.

Sarah: Hey friends, today I have brought a guest on the show to talk to you guys all about some of the core pieces of being a new nurse practitioner, billing, and coding.

Billing and coding are integral but sometimes cumbersome pieces of your new nurse practitioner journey. And so we wanted to provide you with some solid information about not only how to do this correctly, but also on how to be as efficient as possible when you do so you’re not spending hours or even spending time past your office hours all consumed in your charting, because they all kind of go hand in hand.

So thank you, Erica, for coming back to the show with me. And I’m sure this episode is going to be an important one, both for our students who are learning and our new nurse practitioners out there too that maybe didn’t get this exposure during school.

Erica: Yes, thank you for having me on, Sarah. I’m excited to share my insight and help give some helpful tips.

Sarah: Yeah, absolutely. So to kind of dive right in a little bit I think one of the biggest hiccups with billing and coding is kind of what I just said, that not every student really gets to practice that while they’re in school. And so the way I would kind of like to start this episode, even as silly as it sounds, it’s just with you describing what each of these are, and why they’re important.

Because I feel like we need to start there to make sure we’re encompassing everyone and where various people are going to be at when they’re listening to this episode.

Erica: Absolutely, and I totally agree. I think in school I had one maybe 45 minute long lesson on how to chart and how to bill and code, and that was just not enough. And I think a lot of new nurse practitioners struggle because that’s not something that we really learn in school. And yet, it’s so important for our documentation.

And we have to remember that healthcare is a business and as nurse practitioners it is our role to bring in that income. So we want to make sure that we are accurately coding to then bill the patient’s insurance. So, definitely a huge stressor, especially for new nurse practitioners.

Sarah: Yeah, most definitely. I think my experience in school with billing and coding, and really charting in general, my very first clinical preceptor I had was like, “Okay, I’m going to have you chart on every patient.” And it was super overwhelming, and I felt super lost.

But obviously by the end of it I had kind of gotten the hang of it. And then I went into that next clinical and I had a much more reserved preceptor. And she was like, “I don’t want you to touch the charts at all.” So I kind of had both ends of the spectrum. So then by the time I graduated I’m like, “I think I have a general idea.” But almost like I needed a crash course just in billing and coding.

Erica: Yes, absolutely. And really, I mean, we did not get a lot of feedback in school. I remember having to log each case in Typhon. And then you had to enter a code, but there was no feedback if that was the right code or not. And, I mean, same thing for me, my preceptors didn’t really teach me that part of it. So definitely a struggle starting out.

Sarah: Yeah, and I definitely think that’s why people feel so lost too in the beginning. Especially if you had some more of those reserved preceptors that weren’t really letting you get into the charts. Because really, my only saving grace was my one at the end. She was like, “You’re about to be a nurse practitioner so let’s do it all.” And she kind of walked me through how you decide the levels for the patient for the visit, and those sorts of things.

And even that part was something I didn’t really get in the beginning. So I didn’t realize what a tool that was going to be, especially because I’m not sure that my school ever really had much of a class on it. Or if they did, it was so brief I don’t remember it, which is kind of sad.

Erica: Yes, absolutely. So what I’m going to talk today about is mostly the changes for the evaluation and management coding, so E&M coding that came into effect January 2021.

Originally, the rules were created in like 1995, 1997. So they were very much outdated. But the new changes are in effect for outpatient services. So that’s what we’ll be talking about mostly today.

Sarah: Yeah, before we kind of jump into those big changes, where do you feel like with new nurse practitioners, like where do you think they’re having the most issues when it comes to charting and then ultimately, billing and coding?

Erica: Starting out as a new nurse practitioner I think a lot of people are still in that role of a nurse. And the documentation from a nurse to a nurse practitioner is completely different. As a nurse working a 12 hour shift we had to document hourly rounding, and intake and output, and every single thing that the patient did.

I remember learning if you didn’t chart it, then it didn’t happen. And so I think a lot of new nurse practitioners still have that mindset. So they tend to over chart, which takes more time. Also that can open up avenues for legal issues if you’re saying too much and then not addressing every single thing. So that’s definitely a major issue.

And then also for new nurse practitioners, they’re just taking a lot of extra time, which is fine, to look up a treatment plan or a medication dose. And so all of that time can add up. And then nurse practitioners are bringing charts home, spending hours of unpaid time documenting, and it’s really an issue that is causing burnout and work life imbalance. So definitely a struggle for all nurse practitioners, but specifically new nurse practitioners.

Sarah: Yeah, absolutely. So if people are finding themselves kind of staying after work charting, which is oh my gosh, so overwhelming, what would be your kind of biggest piece of guidance or some things that they could do to prevent that from happening?

Erica: Yeah, there’s so many different time saving tips and how to manage your time and the accurately billing and coding. I would say that one of the most important things is to really learn your charting system.

So you can create templates or smart phrases or dot phrases. A lot of charting systems already have these kind of in place too. So it’s going to take more work upfront to learn those things. But ultimately that is going to save you so much time in the long run if you’re able to use those dot phrases. Things that you’re saying over and over again, if you can just have the computer system type that out for you, that saves you a lot of time.

Sarah: Yeah, absolutely. I think there’s a big component of having your system work for you or work alongside you instead of you working for it. And maybe just for people more so out of the loop that maybe haven’t had the chance to chart, can you explain what the dot phrase is or a smart phrase or a template and those sorts of things?

Erica: Yeah, so it depends on your charting system, they call it different things in each charting system. But, for example, the templates are a kind of ready-made, you know, addresses some of the questions that you might be asking.

So say a patient comes in for knee pain, there’s certain questions we’re going to ask for the history of present illness component, and the review of systems, and the exam. And so then if you have a template set up, it brings a lot of that information from the questions that you’re asking or the exam that you’re doing. So it’s really the problem focused, and then it saves you a lot of time from having to type out that whole physical exam, it can kind of pull it through.

And then same thing for smart phrases or dot phrases. Those are generally shorter blurbs. So if you’re constantly giving the home instructions for an upper respiratory illness, if you’re saying that over and over again in your charts, create a dot phrase. And so then when you use that, it will just pull all that information into the chart, so you don’t have to sit out there and type it constantly again and again.

Sarah: I was blown away by templates when I was in that first clinical. And I was in an urgent care setting, and I was seeing probably way more patients than I should have in my first semester. But being in urgent care, especially in the wintertime, it was all cold, flu, strep.

And so to be able to pull that strep template again, and again, and again was so helpful. It was able to let me speed up a little bit. Because if I had to keep continually typing all of that stuff when essentially every person that comes in with strep, for the most part, looks the same. It really made a world of difference.

Erica: Absolutely, it saves a lot of time.

Sarah: So how do you think when you were brand new you mitigated the gap? So how did you kind of transition from being a student and you kind of knew how to chart and bill and code to now being able to do it proficiently?

Erica: Yeah, I mean I had to teach myself because I didn’t learn that in school. So I really watched a lot of training videos and read the documents on billing and coding. And I learned how to create templates within my charting system. And so it did take some more time up front, but once you get used to a lot of those things it ultimately saves you time.

Sarah: Yeah, and I think it’s a really good opportunity to reach out to those around you, working around you, what are they doing? What phrases do they use? What templates do they have? Because every advantage you have when you’re new is going to help, every little one.

Erica: Yes, yes, absolutely. And also, I think, especially for NP students or new NPs, just reviewing documentation. So really looking at that note from cardiology, or from the ER provider, or from their colleagues, and then kind of picking up on what kind of information are they adding? Did they add too much information or not enough? What are some of the phrases that they’re using? So really just being aware of how other people are documenting.

Sarah: Yeah, and I think alongside that too, when you’re a student, especially if you’re in a situation like I was in that second clinical where I wasn’t allowed to chart at all all of a sudden, if you could just even sit and read through how that provider charts, that’s going to give you a big leg up.

Because I remember when we would see hypertension patients, for example, I would write down in my notebook, oh, here are some key phrases that she said. And then I found myself a couple of semesters later when I finally got that chance to chart again, I was going back to all those same phrases again. So that can be really helpful too, just to kind of expose yourself over and over to kind of get the feel for it.

Erica: Yes, absolutely.

Sarah: So the biggest thing I want to talk about today were those billing and coding changes. So can you kind of walk us through all of that, what happened this year?

Erica: Yeah, so with the old guidelines you had to do so many components for the history of present illness, the review of systems, and the physical exam. And so if you didn’t have each one of those bullet points, then you couldn’t code for a higher level.

So if you think about it, an OB provider was having to look at a person’s ears and assess a HEENT when that was really not their main focus. But they wanted to get that higher level of billing. So it was a lot of note bloat, a lot of unnecessary information. And I think that’s what the American Medical Association realized. And so they made these changes for the providers.

So they said you no longer need all of those bullet points. They recommend to have medically pertinent information. So now the provider gets to decide how many review of systems I’m going to look over or what I’m going to do for the exam so we can really shorten our documents and keep them problem focused.

Sarah: Yeah, I think a lot of it’s become a lot more discretionary, which is a huge deal. Because I remember in that very first clinical when I was charting out all those patients and I’d never charted before. And she’s like, “Well, how many points did you meet in the review of systems? And how many points did you meet over here?” And I was like, “What are you even talking about?” I had no idea.

So this is actually a really big deal to cut down on that note bloat because that was definitely how it felt to me at the time. I’m like I feel like I can only say so many things about a patient with strep throat.

Erica: Yep. And then you had to go back through the note and make sure you got all of those bullet points, otherwise you couldn’t bill for the appropriate level.

The other major change that they did was you can now code versus time. So this includes the time that you spend with a patient doing that history intake, doing the exam, doing teaching. It also counts for any time you review documents, you take the time to prescribe medications, or to order labs. And then also it allows you to count the time that you use to document.

So this is major because with nurse practitioners bringing documentation home, we’re spending a lot of time on these notes that we are not getting credit for. So there’s now two ways that you can choose a level of coding, and that is the medical decision making or the time. So they’ve really made it a lot simpler.

Sarah: Yeah. And there is so much time that can go into educating our patients too. I felt like that was so overlooked, but it really can be all consuming.

Erica: Yes, and it’s for the patient’s benefit. You want to make sure that you are spending the time with the patient, and then that you also get credit for that for the billing purposes.

Sarah: Yeah. And something that I wanted to bring up that you mentioned earlier is the legality piece of charting too much. So can you talk a little bit more about that too?

Erica: Yes. So there’s a fine line between charting enough and charting too much. And I think nurse practitioners, and especially newer nurse practitioners, tend to over chart. So they might put information in there that’s not medically pertinent, that’s not specific for that chief complaint. And it kind of depends on what it is, but if you are involved in a malpractice case, that lawyer is going to pick apart your chart.

Sarah: Every last piece.

Erica: Yes, if you said something in the HPI and you did not address that in the rest of your note, they’re going to pick up on that and just tear it apart. So really, I mean, if you review documentation from the ER provider, those notes are straight to the point, they don’t add a lot of extra information. It is just the medically necessary.

Sarah: Yeah, I never want to terrify anyone, but I just want everyone to be cautious of the things you’re charting. So don’t just be charting extra things to be charting extra things because, one, it’s costing you time. And then two, you might have this legality piece down the road which is definitely something you don’t want.

Erica: Yes, absolutely.

Sarah: And I think that I personally might be a little bit too aware of the legality piece because, I mean, I had literally– This was not as a nurse practitioner, I had been a nurse for three months the first time that risk management reached out to me about, ironically, something I didn’t chart that I didn’t realize I was supposed to chart. But just once you have that experience, you’re almost a little spooked.

I think that’s part of bridging that gap from nurse to nurse practitioner, because I felt like as a nurse I needed to chart every little thing. And then trying to revert back as a nurse practitioner was actually really difficult.

Erica: Yeah, and that’s where nurse practitioners think they need to cover their butts so they add in that extra information. And sometimes that’s not the right answer.

Sarah: Yeah. And I think too, you have a course coming out next year about charting, right?

Erica: I do.

Sarah: So tell us all about it.

Erica: Yeah, so my background, I am a family nurse practitioner and a burnout coach. And I help overwhelmed nurse practitioners create work life balance and conquer burnout. And I discovered that one of the major causes of burnout was work life imbalance because nurse practitioners are bringing those charts home, staying late at the office. They always feel behind, feel guilty for having to chart instead of spend time with their families.

So I created the Nurse Practitioner Charting Course to help teach NPs how to chart accurately and efficiently so you can stop bringing those charts home. So it will cover a ton of time saving tips. There’s a section on billing and coding, a section on the legal issues, and then there’s tons of bonuses.

I have some ready-made templates that you can implement and add into your charting system. There’s just a lot of information for new nurse practitioners or other nurse practitioners who just feel overwhelmed with the amount of charting that we have to do.

Sarah: Yeah, just because you’re not new doesn’t mean you’re not overwhelmed for sure.

Erica: Exactly. And I mean, I also want to add it’s not just the charting, we have the patient phone calls or patient messages, there’s medication refills, there’s reviewing diagnostic or specialty notes. There’s a lot of stuff that we have to do as nurse practitioners and so it can be very overwhelming to stay caught up and not to bring those charts home.

Sarah: Yeah, there’s most definitely a lot of moving pieces on top of things like imposter syndrome and everything else that pops up when you’re a new nurse practitioner. So I think this course could be really valuable. When do you think that you’ll be able to release it, or do you have an idea?

Erica: Yeah, it’ll be available January 2021.

Sarah: Boom, boom, so it will be very soon.

Erica: Yes.

Sarah: So if people are out there listening and they want to get a hold of you or get access to this course that’s coming up, what’s going to be the best way for them to do that?

Erica: Yeah, so you can go to my website it’s www.ericadornnp.com. I’m also on Facebook, I have a Facebook page and Facebook group, The Burned-Out Nurse Practitioner. Or Instagram @burnedoutnp.

I also have seven tips that can save hours on charting, so just a quick little free PDF that your listeners can access to learn kind of some of those quick tips. So that is available at www.chart.ericadornnp.com.

Sarah: And I would definitely soak up all the freebies, guys. Anything that can save you time, especially when it comes to something as big as charting, I would go check it out.

Erica: Yes, absolutely. And I think starting out as a new nurse practitioner, this is the perfect time to start to set those healthy habits and to start to learn what you should and shouldn’t chart. Because that’s going to save you a lot of stress and overwhelm and burnout in the future if you can kind of learn those things up front.

Sarah: Yeah, and I’ll just help you structure out better work life boundaries, too. So I think it all kind of goes in together.

Erica: It does, yep.

Sarah: Well, thank you so much, Erica, for coming to the show again. I really appreciate it.

Erica: Yeah, thank you for having me.

Sarah: Yeah. And I’ll talk to everybody else next week.

As an extra bonus, friends, if you’re looking for support no matter what phase of your nurse practitioner journey that you’re currently in I have communities available for both students and new nurse practitioners. In these communities, we work to uplift one another and grow this profession together every single day. Links to join will be included for you in the show notes.

Thanks for listening to Becoming a Stress-Free Nurse Practitioner. If you want more information about the different types of support we offer to students and new NPs, visit https://www.npreviews.com/resources. See you next week.