Basic Rules for Medical Coding

Basic Rules for Medical Coding

Medical coding makes the billing process much easier because it brings uniformity to the process through the use of easily recognizable codes. When these standard diagnosis and procedure codes are used, the insurance companies and various medical service providers are able to recognize them- which means that the bill will be paid and why the particular procedure, treatment, or test was used.

While it’s true that there are a variety of coding techniques based upon the particular medical specialty, there are definitely always some basic medical coding guidelines that are always applicable.

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Only Code Documented Information

The job of the physician is to accurately document the procedures, tests, and services performed, as well as detailed descriptions of the conditions, complaints, injuries, symptoms, and illnesses of the patient. The medical coder must make sure that the codes on the medical claim are in agreement with the information found on the medical records.

Be Sure Codes are Reported in Proper Order

When it comes to medical coding, not only is it critical to accurately code the diagnoses and procedures, it’s also critical that they be coded in the correct order. The very first code listed should always be the reason for the patient’s visit to the physician, even when there are other diagnoses and symptoms and when multiple procedures or treatments are performed.

Be Sure to Follow MUE and NCCI Guidelines

When you are dealing with Medicaid and Medicare, you must realize that there will be some slight differences in coding regulations than you have with other insurance companies. As a medical coder, you must report the units of service based upon the Medical Unlikely Edits, or MUE, and the National Correct Coding Initiative, or NCCI.

This will help you avoid reporting multiple procedures or services that should not be billed in conjunction with each other because one most likely includes the other or because it’s medically unlikely that the two procedures would be performed on the patient in the same day.

The Centers of Medicare and Medicaid Services, or CMS, developed the National Correct Coding Initiative to avoid any inappropriate Medicaid or Medicare payments as a result of errors in coding. You will find that there are three forms of NCCI edits. They are as follows:

  • Procedure to Procedure Edits: this is a type of edit defined by CPT and HCPCS codes that do not need to be billed together. If they are, one or both of them is likely to be denied.
  • Medical Unlikely Edits: this is a type of edit that that is defined by CPT and HCPCS codes with a specific number of units that are not likely to be billed, even if the claim is correct. In some cases, the units of service that exceed what is thought to be medically necessary are most likely to be denied.
  • Add-on Code Edits: this type of edit helps prevent payment of additional codes that are considered to be included in the primary HCPCS and CPT codes.

Stay Aware of Changes in the Coding Industry

There are a variety of components involved in ensuring that a claim is accurate. Some of the best ways to make sure the medical claims are accurate is to stay aware of any changes in the coding process each year, making sure that you follow the standard guidelines, and making sure patient records are detailed.

The codes on the claim explain to the payer the illness, injury, or symptoms of the patient and the method of treatment employed by the physician. A mistake in coding the claim occurs when the claim is submitted with the wrong procedure or diagnosis code. Inaccurately coding a claim can result in a negative outcome. It is critical that there is a compliance system in place that can help avoid medical coding requirement violations.

Be Sure to Use Appropriate Modifiers

You will find that some of the HCPCS and CPT codes do require modifiers. This is a code consisting of 2 numbers, 2 letters, or 2 alphanumeric symbols. The modifier gives additional information regarding the procedure or service that was performed.

They are used to point out the area of the body where the procedure was performed, several procedures performed at once, or show that a procedure started but then was discontinued for one reason or another. The definition of a procedure code is not changed by the modifier, but it is added to.

Key Facts about Modifiers:

  • There are some of the modifiers that cannot be used with some of the HCPCS and CPT codes.
  • You should refer to the NCCI, or National Correct Coding Initiative for appropriate Medicaid and Medicare coding.
  • Make sure you are familiar with the modifiers that are often used improperly or overused.
  • Remember that inappropriately coding the modifiers can result in a reduction or delay of payment.

These basic medical coding guidelines will help you ensure that the medical professional you are working for gets paid properly and in a timely manner.

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