Just as medical transcriptionists must be extremely accurate in their work- transcribing medical reports- medical coders must be meticulous and thorough.  It is not enough to skim through a medical report and quickly apply the appropriate codes for diagnoses and procedures.  A good medical coder must take time to thoroughly read and understand the patient medical record to make sure that the diagnosis selected is supported by corresponding documentation in the medical record.  Additionally, any procedures performed must be backed up by a corresponding diagnosis.  Whereas most working medical coders understand this fact, it is still easy to become a little complacent and sloppy particularly if charts are backed up and the work pile is pretty deep.   However, with what’s a stake (with all the regulations and legal ramifications), it is really important to take steps to make sure that all is being done to ensure successful and accurate reporting and balance that need with the requirement for fair and equitable reimbursement for medical coding certification.

Some quick tips to help ensure successful and accurate coding is as follows.

  • Always file claims electronically whenever possible to cut down on lost claims and to speed up the reimbursement process.
  • Remember to document the verification of patient coverage, and any appeals process during the reimbursement process.
  • Keep up to date on payers policies, rules, and contract guidelines.  This helps to avoid denials of claims and speeds the reimbursement process.
  • Don’t let claims build up, and then feel under pressure to get through a mountain of files.
  • File claims on a daily basis.
  • Check claims for errors BEFORE filing with the payer.
  • Check to make sure that the diagnosis is backed up by facts in the medical record.  This way if the clinic is ever audited, you will not have to worry about what appears to be fraudulent claims.  Even if you use great coding software such as Alpha II, still cross-check for accurate coding.

By being diligent in your medical coding and billing practice, you avoid the pitfalls of sloppy coding and accidentally up- or down-coding.  Virtually every medical provider now needs business and medical staff who are well trained to insure the practice is successful and is in compliance with the increasing rules related to conducting a practice. Coding and billing are critical issues in the practice of medicine with lots of federal funding in place to do audits, particularly of Evaluation and Management Codes (the government now has lots of data on those). Med-certification and its affiliate programs will increase staff awareness of the real issues and the penalties. Experts recommend that practices commence formalizing policies and procedures and develop complete compliance plans.