Is Your Coding Up to Par?

Coding is at the heart of accurate medical billing. It determines if you collect everything you are owed since payment must reflect exactly what was done and “If it isn’t documented, it wasn’t done.”

It would be great if there were some way for the physician’s actions to magically translate to physician billing and payment. But since that problem hasn’t been solved yet, we have to use physician documentation to determine payment by way of Diagnosis Codes (ICD-10) and procedure codes (CPT).

While everyone understands this basic process, it’s amazing how often mistakes or inconsistencies arise. Sometimes they are caused by complex situations that aren’t black and white. But more often, it is because coders aren’t properly trained (and, in some cases, not certified) or they are overloaded. ICD-10 has magnified concerns with its explosion of new codes. Common mistakes that we see include “assumptive coding” where the coder reads between the lines and assigns a CPT code that isn’t fully reflected in documentation. Their assumption may be correct but, if the claim is denied or challenged, there will be no documentation to back it up. in other cases, the minimum requirements for what must be included in the medical record aren’t met: e.g. history of present illness (HPI), examination, and medical decision making (MDM) for evaluation and management (E&M) services.

A more insidious mistake is when the coder doesn’t pick up everything that was done. This can happen with supplies or ancillary services. Or where an encounter is downcoded by not questioning inconsistent information in the documentation. In the latter case, good coders will ask the physician to clarify the documentation (via an amendment).

In fact, regular and effective communication with physicians is essential for coding success. This should take the form of daily/weekly questions about individual cases and monthly or quarterly feedback on patterns and areas for improvement. Plus updated and new regulations.

Not sure about your coding effectiveness? A third-party coding audit is an inexpensive way to find out. By having a small sample of cases audited, you will quickly learn if you are missing revenue and/or taking undue compliance risks.