Three questions to consider before assigning a medical code
In today’s data-driven healthcare environment, medical codes drive everything from payment to quality reporting to public health initiatives and more. That’s why it’s so important to assign the right ones based on the patient’s clinical presentation and the services they receive. Revenue cycle management (RCM) experts often use the phrase, ‘Garbage in, garbage out,’ meaning if the data you capture isn’t accurate, the insights you glean from that data won’t be accurate either. Neither will your medical practice reimbursement.
Another point to remember: If the medical codes you assign aren’t correct, the medical bills patients receive won’t be right either. Inaccurate medical bills can lead to a whole host of other problems, namely patient dissatisfaction and aging accounts receivable (A/R). If you want to build patient engagement and improve RCM in your medical practice, one way to do that is by avoiding common errors and focusing on the accuracy of your medical coding.
The challenge? Medical codes evolve, oftentimes becoming more specific and granular. Other times, codes are deleted, and new ones created. For example, new, revised, and deleted diagnosis codes take effect twice a year – April 1 and October 1. Here’s a link to the April 2023 updates and another to the updates for October 2023.
Major updates to CPT codes take effect January 1 with minor updates occurring quarterly. There are also quarterly updates to HCPCS Level II codes for drugs, supplies, equipment, and non-physician services. If you don’t know what these updates are and how they may affect your specialty, it becomes impossible to promote data and payment integrity in your medical practice.
Following are three questions to consider before assigning a medical code:
1. Do the medical codes tell the story of what happened?
What is the patient’s reason for coming in? What additional diagnoses, if any, affect their treatment and the physician’s medical decision making? Once you note the appropriate conditions, look them up in the alphabetic index of the ICD-10-CM Manual. Pay attention to information such as ‘see,’ ‘see also,’ ‘with,’ ‘without,’ and ‘due to’ because these terms may indicate you need to look elsewhere in the manual to assign the correct code.
What services or procedures did the physician perform during the encounter? What descriptors denote those procedures or services? Look them up in the index of the CPT Manual. Then verify the code selection in the main text. Be sure to append any CPT modifiers, if needed.
2. Did you capture specificity and medical necessity?
It may be tempting to choose the first medical code that’s available in the electronic health record drop-down menu but doing that can jeopardize medical practice revenue.
For diagnosis codes, verify the medical code in the tabular index of the ICD-10-CM Manual. This is where you’ll find additional information and instructional notes to help you assign the most accurate and complete medical code. For example, the tabular list includes information about severity, complications, excludes notes, and whether you’ll need to assign any additional codes. Also be sure to check chapter-specific guidelines to determine correct sequencing and any additional requirements.
On the CPT side, if you’re reporting an evaluation and management (E/M) code for an office visit, does the E/M code seem to be justified given the patient’s severity of illness and risk of mortality? In other words, is the E/M level medically necessary?
3. Did you leverage all healthcare revenue cycle technology and tools available to you?
For example, does your claim scrubber alert you to any potential errors or omissions? What about other edits you’ve put into your practice management system? Be sure to fix any errors prior to claim submission to avoid potential denials and recoupments. The goal is to keep your healthcare revenue cycle running as smoothly and efficiently as possible.
Tap into certified medical coders
Certified medical coders can be a huge help in any medical practice—whether it’s coders you employ directly or ones you work with through an outsource partner. These highly trained individuals understand the complexity of medical coding, including coding guidelines, documentation requirements, and payer-specific nuances. Medical coders are an essential part of a healthy revenue cycle.
Conclusion
Accurate medical codes depend on your ability to tell the patient’s story with specificity and accuracy, and healthcare revenue cycle technology plays a critical role. Learn how edgeMED can help and be sure to check the Healthy Snacks blog for more expert insights, best practices and industry trends.
