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Medical Coding and Oversight

Medical Coding and Oversight

Nowadays, medical coding plays an essential role in every medical practice, whether public or private. Medical coding involves taking information associated with medications, diagnoses, procedures, treatments, and translating them into alphanumeric codes. The medical information comes from several sources, including lab results, electronic health records, medical notes, and many more. While it does not require several years of going to school, medical coding does require proper training, accuracy, attention to detail, and in most instances, experience. As a medical practitioner, everything that is documented in your notes contributes to determining the level of care you provide to your patients. This, in turn, determines the medical claims that are billed to the insurance company and to the patients. For this reason, it is important that you not only understand the significance of clear and detailed documentation but also the effects that such documentation can have on medical care, particularly increased medical costs.

In today’s world of medicine, having a proper medical coding system is crucial for proper reimbursement, demographic studies of disease occurrence, as well as treatment outcomes. Like it or not, any medical errors that may arise become the medical practitioner’s fault. Ultimately, it is you who can get audited – not the medical coder nor the patient billed. So if you own a private medical practice, it may be in your best interest to refer to a billing and coding company for your medical coding. Most experts reveal that medical coding should be a shared responsibility.

Without the help of medical coders, medical practitioners such as you, would have a difficult time keeping track of your patients’ health records and necessary billing for rendered services. A medical coder generally works close with medical practitioners, nurses, and other medical staff members. They have a responsibility to make sure your practice is complying with the latest rules and regulations. They also use the International Classification of Diseases (ICD) medical coding system in order to identify and assign the right code to each patient’s individual case. A medical code is a code, or rather a definition, that represents the specific medical condition a patient is experiencing. As with all medical codes, ICD-10 codes are intended to portray the exact aspect of the health-related findings. A few examples of ICD-10 codes include the following:

  • W20.8xxA - Struck by falling object (accidentally), initial encounter
  • V91.35 - Struck by falling object due to canoe accident
  • W61.62XD - Struck by duck, subsequent encounter.
  • S06.0x1A - Concussion with loss of consciousness of 30 minutes or less, initial encounter
  • W52.XXXA - Crushed, pushed, or stepped on by crowd or human stampede, initial encounter
  • V80.731A - Occupant of animal-drawn vehicle injured in collision with streetcar, initial encounter
  • C50.511 - Malignant neoplasm of lower-outer quadrant of right female breast
  • C50.512 - Malignant neoplasm of lower-outer quadrant of left female breast
  • S10.87XA - Other superficial bite of other specified part of the neck, initial encounter
  • FI0.92 - Alcohol use, unspecified with intoxication
  • F03.90 - Unspecified dementia without behavioral disturbance
  • V00.01XD - Pedestrian on foot injured in collision with roller skater, subsequent encounter
  • I11.0 - Hypertensive heart disease with heart failure
  • T63.012A - Toxic effect of rattlesnake venom / intentional self-harm
  • T7501XD - Shock due to being struck by lightning, subsequent encounter
  • T82.329A - Displacement of unspecified vascular grafts, initial encounter
  • K50.011 - Crohn’s disease of small intestine with rectal bleeding
  • F90.9 - Attention-deficit hyperactivity disorder, unspecified type
  • S24.0xxA - Concussion and edema of thoracic spinal cord, initial encounter
  • I11.0 - Hypertensive heart disease with heart failure
  • R87.5 - Abnormal microbiological findings in specimens from female genital organs
  • W10.9xxA - Fall (on) (from) unspecified stairs and steps, initial encounter
  • J45.51 - Severe persistent asthma with (acute) exacerbation
  • F32.9 - Major depressive disorder, single episode, unspecified
  • F32.9 - Major depressive disorder, single episode, unspecified
  • F10.99 - Alcohol use, unspecified with unspecified alcohol-induced disorder
  • I82.401 - Acute embolism and thrombosis of unspecified deep veins of right lower extremity
  • P96.1 - Neonatal withdrawal symptoms from maternal use of drugs of addiction

In an outpatient setting, an ICD code is assigned only when a definite diagnosis is made. A condition that remains undefined is never assigned a code but rather only the symptoms are coded. In an inpatient setting, the same is true only when tests have been performed to rule out other medical conditions. At times, the terminology, or rather coding, may not be immediately evident. Therefore, it is necessary for both parties to communicate on a frequent basis so as to gain clarification. Both you and the medical coder should meet every six months in order to make sure that you are both on the same page. Being that medical coding is part of federal government regulations, if an audit indicates that your practice is falling below the acceptable level, you may be fined a significant fee. Therefore, you and your medical staff should be aware of such mistakes and understand how to handle them. The periodic audits scheduled should reflect the necessary changes that are made within your practice.

In many ways, technological advancements have appealed to both doctors and patients. Building apps are now used to monitor patients’ health at home, innovative technologies (video conferencing, virtual consultation monitors, and mobile health monitors) are used to tackle and improve clinical processes, and electronic health records (HER) have become adapted to improving patient outcomes. Electronic health records also provide you with vital patient information and they strive to reduce medical errors. Moreover, there are now hundreds and hundreds of mobile health apps, all designed to do everything from recognizing symptoms to tracking fitness programs. Today, being a tech-savvy medical practitioner can help you to reach out to patients and assist them in finding reliable health-related information. What’s more, you can do your own coding if the technology is made available to you.

Ideally, you should be involved in your own practice’s medical coding; however, there are also several disadvantages to medical practitioners being the only coders. You have to be able to keep up with patient information at all times, you have to hold numerous meetings on an annual basis, and you must enter information into the billing system that is accurate and meets audit expectations. To provide assistance, staff members are now trained to question a practitioner’s decisions for the betterment of the patients and the practice. By working together, you can increase patient satisfaction, all the while cutting costs of care.

Medical coding and billing rules and regulations change on a constant basis and your practice must change with them. In order to do this, you and your medical staff must stay well-informed and receive the latest training and education on coding and billing. Seminars and on-site trainings are just a few of the methods that can be of great advantage to both parties. While such methods may seem as added expenses, the benefits outweigh the costs. Besides, there are several organizations that even offer online training and seminars free of charge, including Medicare and Medicaid. Continuing education and training is a worthwhile investment that will only lead to increased revenue in the future.

Realistically, medical practitioners’ who do it all without making a few mistakes along the way do not exist. This is where medical coders step in. A medical coder should be comfortable in his or her surroundings. They should feel free to advise you on medical documentation or seek clarification on a service that you have performed. At the same time, you should be willing to accept their advice. When it comes down to it, you can greatly benefit from learning medical coding and billing rules and regulations. With the amount of effort you invest into your patients’ care, medical coding is simply a way to tell the whole story in regards to maintaining adequate reimbursement and possibly raising compliance issues.