As a reimbursement requirement, coding has been around for over fifty years and has grown in importance. It is the way providers define and justify a patient’s level of service and the severity of their diagnosis for billing purposes. Whether in an acute-care or ambulatory setting, ICD-10-CM and -PCS, CPT, and HCPCS coding is of paramount importance to maximizing insurance
reimbursement and avoiding claim denials and rejections.
Coding, with all its intricacies, can impact revenue and bottom-line results in a significant way. Your current Revenue Cycle Management (RCM) model may rely on in-house coding support like most practices, and this may simply not be adequate. By engaging a Medical Coding Partner, your practice could jumpstart the process of improving your coding program going forward.
Coding Challenges Supported by a Medical Coding Partner
The invaluable benefit that a medical coding partner brings to a practice is undoubtedly a fresh pair of eyes. In the day-to-day business of RCM, it’s easy to become singular in focus. An
objective, third-party review is a terrific way to audit the processes being used and to recommend, train and help implement changes that transfer directly to the bottom line.
During the medical claims adjudication process, insurers decide if the diagnosis and treatment match with the standard of care in the community and are appropriate for the injury or disease
being treated. If there is a discrepancy, the claim is denied or rejected and, if not followed up, the revenue is lost completely. The goal of every practice is to maximize reimbursement and to collect that revenue in the shortest amount of time possible.
The Challenge of Coding Complexities
Understanding coding complexities can be an overwhelming task and one that has long-reaching consequences. Not only are coding results monitored by insurance payers, but there can be serious legal and financial ramifications if miscoding is persistent and unabated. Let’s look at some of the challenges and hazards.
- Correct Code(s) Selected – was the right CPT code selected for the services performed and any associated procedures and tests, and was it coded with the proper ICD-10 diagnosis code?
- Level of Specificity – were ICD-10 Codes selected that were not specific enough when each diagnosis must be coded to the highest level (maximum number of digits allowed)?
- Correct Order – the first code must always be the specific reason for a patient’s visit or risk rejection by insurance payers.
- Unbundled Charges – procedures or tests that are being charged separately when they are designated as part of a diagnosis bundle.
- Upcoding or Downcoding – coding should be for the exact level of service performed, and there can be significant consequences if a practice continually up or down codes the work performed.
- Appropriate Modifiers – using inappropriate modifiers for CPT and HCPCS codes, particularly the unspecified code.
- Documentation – every visit should be adequately and timely documented not only to provide information on a claim-by-claim basis if requested for reimbursement but also in case the practice be audited by an insurance provider or governmental agency.
Services of a Coding Partner
Medical practices are busy; their day-to-day care schedules and RCM clip along at a fast pace. It’s not always easy for the employees responsible for such an important function as medical
coding to take the time to audit and perform quality control, let alone keep up with the latest updates and regulatory changes. It often seems they’re spending every minute just keeping the
By engaging a medical coding partner you can expect:
- Better reimbursement and greater efficiency with a thorough knowledge of primary and
specialty coding, as well as inpatient experience,
- Comprehensive understanding of the insurance payer market in your area and
- Strong communication regarding data analytics and process improvements–know where
you stand financially,
- Ongoing training and education for providers and business office personnel, and
- A robust compliance and ongoing quality improvement program.
What can a medical coding partner do for you? You could see an almost immediate increase in revenue with an overall improved coding strategy and execution. A partner such as Enhanced
Revenue Solutions can guide you towards a high functioning and well-trained coding program that captures the maximum reimbursement for the services you provide.
Find out more today about our free A/R report card and coding assessment