Coding Frequently Asked Questions – FAQs

How can we ensure that our coding and documentation practices are optimized to achieve the highest possible revenue reimbursement?

• Conduct a well-rounded Provider and Coder audit cycle with a comprehensive scoring report.
• Implement a well-maintained coder training program and provider education curriculum.
• Establish a centralized library of resources for providers and clinical leadership (cloud page, SharePoint).
• Schedule strategic interdepartmental revenue cycle meetings with a regular scorecard report cadence.
• Ensure a coding department presence in monthly clinical meetings.
• Regularly update compliance and revenue billing systems quarterly for current revenue code sets and revised Chargemasters (CDM).
• Implement an all-encompassing Target, Probe, and Education (TPE) Program.
• Engage external audit partners to ensure the effectiveness of items 1-7 and maintain proper cadence.

Conduct an external review of the current audit cycle, scoring, reporting, and education program. The audit cycle program should have strategic oversight, providing meaningful data reports for both clinical and financial leadership. These reports should address issues and trends, facilitating ongoing process improvement:

• Monthly provider documentation and provider code selection audits.
• Monthly coder audits focusing on code change trends.
• Provide healthcare provider education and training based on audit results.
• Stay updated on annual coding changes.

 

How does coding and documentation impact maximum reimbursement?

Documentation Impact:

• Payers may reject/deny claims citing insufficient documentation.
• Providers may fail to code and bill for services documented.
• Providers may inadvertently engage in inappropriate unbundling while documenting, coding, and billing services.

Coding Impact:

• Payers may reject/deny claims due to inappropriate ICD/CPT/HCPCS/MOD codes.
• Consistent coding oversight is crucial, preventing errors such as combining diagnoses under specific conditions.
• Procedural coding oversight is vital, ensuring certain services are not billed together when one is more comprehensive.

To optimize reimbursement:

• Regular provider documentation reviews and ongoing coder pre-bill reviews are essential.
• Consistent targeted meetings with billing and collections departments are necessary.

 

How do billing and coding regulations affect reimbursement

Coding is intricately tied to billing and is governed by extensive rules and regulations embedded in payer systems that are becoming more sophisticated.

Successful organizations require intelligent systems where coding leadership comprehends the influence of billing, contracts, and reimbursement to maintain consistent system intelligence, integrations, and optimize training for employees and providers.

 

How can medical billing and coding negatively impact patient satisfaction?

Coding: 

• DX Coding: Precision in diagnosis coding is crucial. A deep understanding of ICD-10-CM coding guidelines is essential when reviewing a provider’s documentation to assign the most accurate code to the patient’s record. Any ambiguity in the provider’s documentation and diagnosis code selection requires querying the provider for clarification. Incorrect diagnosis coding extends beyond payer denials; it affects the permanent record of a patient’s health and contributes to public health and data statistics.
• CPT Coding: With many rules and guidelines in place it’s important to carefully evaluate management and other services and procedures. Accurate interpretation and coding is critical, as these services form the foundation of any healthcare organization. Ensuring medical necessity requires consistent coder and auditor reviews.
• Incorrect or inappropriate coding and billing of diagnoses and services can create a misleading portrayal of the patient’s medical history, potentially resulting in surprise billing and patient disputes. This may prompt patients to contact payers and insurance commissions to report fraud.

Billing: 

• You’ll need to ensure accurate billing based on documented services and their medical necessity. Precision is essential to prevent over-coding, which could lead to excessive costs for both payers and patients, while also avoiding under-coding. This applies whether patients have insurance or not.

 

How does medical coding affect reimbursement?

Medical coding has a broad impact on reimbursement. Frequent rejections or denials from payers often stem from inappropriate or incorrect coding combinations. To navigate fee schedules and payer behaviors related to services performed, a comprehensive understanding of coding rules and guidelines is essential. Documentation of coded services must be thorough, compliant, and medically necessary to ensure clean claims from a coding perspective.

What is the medical billing process?

The medical billing process is a workflow with multiple operations that must flow together to have a strong and optimized revenue cycle.

• Intake: Begins with patient demographics and insurance coverage or the lack of insurance coverage. This insurance information must be entered into the system with accuracy and the benefits (based on specialty) must be validated through RTE, IVR or other online portals or a call in to speak with a representative.
• Visit: Next is scheduling the patient and the intent of the visit. More importantly, is understanding the patient’s responsibility prior to the visit. As today, patients are responsible for more out of pocket; therefore, patient collections must be optimized UP FRONT! Patient sees the provider, the medical record is documented, services are performed, codes are selected.
• Coding: Codes selected by provider and/or reviewed by coders are submitted for billing. Billing department (depending on bill cycle) clears any upfront system edits and submits batches to payers.

• Submit Bill To Payer: Payers may reject at the gate and billers reconcile rejections for resubmission. Payers take claims into a worklist where humans or systems process (adjudicate) the claims for payment or denial.

• Reimbursement (Payment and/or Denials): Adjudicated claims are sent back through the submission portal and begin the aging process in the billing department.

• Collections: Returned claim payments and denials are posted to the patients account. Paid claims are closed and denied or patient responsibility claims are placed in the AR buckets for collections and follow up
• Repeat

How to improve documentation to support coding and billing for maximum reimbursement?

The most effective approaches to improve documentation are:

• Consistent coder pre-bill reviews
• Ongoing retrospective audits 

These two methods are surefire ways to improve documentation accuracy, ensure medical necessity, and maximize reimbursement.

 

What are the coding systems used in the reimbursement process?

• Optum
• 3M
• Nuance
• TruCod
• Meditech
• Vizient

What are the three components of reimbursement?

• Fee-for-Service
• Bundled Payments
• Capitation
• Value/Risk Based Payments

 

What are the four main methods of reimbursement? 

• OPPS
• IPPS
• DRG
• APCs

 

Why is it important for documentation?

Documentation is important because it illustrates the patients clinical-medical needs, the presentation of diseases and conditions, the services ordered-reviewed-analyzed to tie together and to manage the care plan which is designed to get or to keep a patient at a baseline of health or healthier.

 

Can we provide and bill for both preventive/wellness and illness services during the same visit?

YES, based on the intent of the visit:

1. Patient is scheduled for both a preventive/wellness visit and a problem visit
2. Patient is scheduled for a preventive/wellness visit and either the patient reports a complaint (ie; back pain, chest pain, feelings of depression). The provider then separates out the complaints to address the “problems” and applies Medical Decision-Making or Time to evaluating the problem(s) 

When a significant illness/injury is addressed and evaluated during the course of a preventive visit (annual physical, wellness visit) that service when documented appropriately can be coded and billed in addition to the preventive service.