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Feel confident that you have knowledge to offer.

Coders may have nightmares about the awkwardness of approaching a physician and giving them tips on how to do their job. But coders shouldn鈥檛 forget that they have specialized knowledge 鈥� and expertise 鈥� that physicians and other providers don鈥檛 have!

鈥淚t can be intimidating to give feedback to providers, but part of our job is to assist providers in getting their services accurately reported,鈥� said Shea Lunt, CPC, CPMA, RHIA, during her AAPC鈥檚 HEALTHCON 2025 presentation with Emily Lomaquahu, CPC, CPMA, CEDC, 鈥淓nhancing Provider Education.鈥�

Read more about why communication is crucial to the coder-provider relationship, especially when working together to report evaluation and management (E/M) services.

See Communication As Foundation of Relationship

Coders should rely on their expertise of their subject matter: Their job is to report codes to most accurately describe encounters or diagnoses as documented by providers.

Sometimes situations arise where a coder sees a discrepancy between the E/M service code the provider selected and what would best reflect the encounter, relies on their expertise to select the more appropriate code, and then submits the claim, all without communicating what happened to the provider.

Even if the coder doesn鈥檛 want to bother the provider, failing to communicate what happened can lead to a lot of frustration for both team members: Coders are constantly fixing the provider鈥檚 misinformed code choices, and providers may not realize why the reimbursement they received may not have been what they anticipated. Without sufficient clarity and communication, the coder-provider relationship can deteriorate over these kinds of misunderstandings or misinformation.

Solve the Problem Through Education

The best way to have a candid and productive conversation about coding with a provider is to do so in a safe space.

鈥淵ou don鈥檛 want to enter these situations like a bull in a china shop!鈥� Lomaquahu cautioned.

Plan your approach to a meeting 鈥� and the meeting itself 鈥� by thinking about your mindset and what you鈥檙e bringing to the interaction. The dynamic shouldn鈥檛 be 鈥渃oder versus provider鈥� but a team looking to provide care and get paid for their services. Rely on the E/M definitions and guidelines to support your explanations, and focus on how you鈥檙e going to communicate the information.

鈥淲hat we need to do now is develop a way and open up the lines of communications between the coder and the provider,鈥� Lomaquahu said. 鈥淚t could be setting up recurring coder/provider meetings, maybe once a month to look at a couple of charts together and discuss them. It could be having the coder, if they鈥檙e noticing trends in the documentation, like selecting higher levels of service than are supported, put together and send an email.鈥�

Regardless of the method or frequency, you want to prioritize establishing and maintaining trust.

鈥淩ecognize that this is a collaborative effort and that everybody really has the same goals: Those goals are going to be improved documentation and coding,鈥� Lomaquahu said.

Don鈥檛 forget to make space for feelings. Providers did not go into medicine for the charting and coding 鈥� they prioritize patient care. 鈥淎pproach the discussion from a place of understanding: Charting is probably one of their least favorite activities of all time,鈥� Lomaquahu said. As a coder, you know that they鈥檙e the expert on the clinical aspects, but it鈥檚 OK to feel confident in your knowledge of the guidelines and rules for documentation. Commiserating with them a bit on the difficulty of charting and listening to their frustration can go a long way in helping them feel heard 鈥� and therefore more receptive to the education you鈥檙e trying to provide.

Solicit Questions Ahead of Time

鈥淎lways, always, always ask for questions ahead of time, because the more you can be prepared to talk about those specific questions the provider has been having, the more successful you鈥檙e going to be,鈥� Lunt said. Don鈥檛 forget to look for issues identified by other departments in your organization, like the billing team or the denials team.

Remember, too, that a meeting doesn鈥檛 have to be limited to just a one-on-one meeting between a coder and a single provider. If you organize a general educational meeting, you might have the practice manager or chief of staff involved, or a larger audience, and it鈥檚 important to try to know that ahead of time and to anticipate what questions their unique roles and perspectives might bring, too.

There are pros and cons to each approach, but both Lunt and Lomaquaha say 45 minutes of content is a good target, leaving time for questions that may arise without burning through everyone鈥檚 attention span.

In a one-on-one meeting, you can go over that specific provider鈥檚 charts and have a more informal conversation, which can bolster the relationship, Lunt noted. 鈥淚n our experience, one-on-one education is super helpful for providers who are new or maybe new to the organization or to billing,鈥� she said. She recommended offering a one-on-one session if a provider ever requests meeting or more information about anything specific, like leveling an encounter.

Larger group meetings may be more efficient because you have a lot of people together at once and have multiple perspectives available. 鈥淵ou can get a lot of providers at once in some of those sessions, and all the attendees are going to receive the same information, which is helpful when you鈥檙e presenting on documentation, because they may develop templates,鈥� Lunt said. This approach is especially helpful for addressing annual audit results or yearly trainings, or to deliver pertinent coding updates.

While in-person meetings may feel the most natural and be the best for strengthening relationships, virtual or phone meetings can work, too. You can ask the clinic or practice manager to help with scheduling or try and tack your session onto the schedule before or after an established, regular meeting.

Now that you鈥檙e prepared to schedule a meeting, look for next month鈥檚 RCI article for tips on what to do during the meeting to make sure you鈥檙e effectively communicating specifics of E/M coding to providers.  

Rachel Dorrell, MA, MS, CPC-A, CPPM, Development Editor, AAPC