By Nicola Hawkinson, DNP, RN, RNFA, CPC

Accurate Current Procedural Terminology® (CPT) coding is not only essential for financial stability but also directly impacts patient care. Healthcare systems face significant financial losses due to coding errors. According to recent data, hospitals across the country lose approximately $262 billion per year due to denied claims from insurers, leading to cash-flow issues and recovery costs. Additionally, an estimated 9% of hospital charges are denied annually, putting nearly $5 million per hospital at risk.

Preventing Coding Errors: The Importance of Provider Documentation

We frequently see coding errors stem from inadequate provider documentation. Coders face challenges in accurately translating patient encounters (e.g., office visits, surgery) when clinicians fail to provide comprehensive details about symptoms, diagnoses, previous treatments or performed procedures. These inaccuracies lead to claim denials, revenue loss, and increased administrative burden.

To address this issue, healthcare organizations should prioritize robust clinical documentation improvement (CDI) programs. These programs involve close collaboration between coders, clinicians, and CDI specialists. By emphasizing precise documentation at the point of care, hospitals can reduce coding errors and enhance revenue capture.

Coder Error: Striving for Coding Accuracy

Maintaining >95% coding accuracy is a critical goal for healthcare systems. Coders play a pivotal role in translating complex medical scenarios into standardized codes. However, staying up-to-date with ever-evolving coding guidelines and updates is challenging. Here are some strategies to enhance coder accuracy:

1. Continuous Education: Regular training sessions keep coders informed about changes in CPT, ICD-10, and HCPCS codes. Webinars, workshops, and certification programs help coders stay current.
2. Collaboration with Clinicians: Open communication channels between coders and clinicians are essential. Regular meetings allow coders to seek clarifications, discuss complex cases, and ensure accurate code assignment.
3. Dual Coding Reviews: Conduct dual coding reviews where two coders independently assign codes to the same medical record. Comparing their results helps identify discrepancies and promotes consistency.
4. Outside Coding Reviews: The purpose of these reviews is to obtain an unbiased assessment to ensure sufficient documentation and coding accuracy; remember, coding accuracy leads to revenue accuracy. The AAPC, the world's largest coder credentialling organization, states: "Both the Office of Inspector General (OIG) and CMS recommend that all physicians and non-physician providers have their coding reviewed by an outside independent party who has the appropriate expertise in that clinical specialty."

Recent Updates (2023 - 2024)

In the ever-evolving landscape of healthcare coding, several notable updates have occurred:

1. ICD-10-CM and ICD-10-PCS Changes: The transition from ICD-10-CM to ICD-10-PCS continues to impact coding practices. Coders must stay informed about new codes, revisions, and guidelines to accurately represent diagnoses and procedures.
2. Telehealth Coding Guidelines: The surge in telehealth services during the pandemic prompted updates to telehealth coding guidelines. Coders now navigate specific modifiers and documentation requirements for virtual visits.
3. Evaluation and Management (E/M) Overhaul: Significant changes to E/M coding took effect in 2023. The revised guidelines emphasize medical decision-making and time spent with patients. Coders must adapt to the new documentation requirements.
4. Surgical CPT Codes/Modifiers: CPT codes are updated annually. Neurosurgeons make a significant portion of revenue by billing surgical CPT codes; therefore, it is essential that coders are up-to-date with all changes. Additionally, modifiers impact revenue so ensure that accurate modifiers are used.
5. Value-Based Payment Models: Healthcare systems increasingly shift toward value-based payment models. Coders play a pivotal role in capturing quality metrics and ensuring accurate reporting.

CORE Medical Revenue Cycle Management: A Solution for Success

Healthcare providers benefit from unleashing the power of CORE Medical Revenue Cycle Management. Founded by Nicola Hawkinson, DNP, CORE provides high-quality, personalized coding and revenue cycle management services. Their clinical expertise helps guide the billing team to submit clean claims that are paid promptly. Experienced certified professional coders (CPC) understand what gets claims paid, minimizing delays. The persistent collections team recognizes that unpaid claims directly impact physicians and their families.

Conclusion

In summary, our commitment to excellence through SpineSearch and CORE Medical Revenue Cycle Management underscores the importance of accurate coding and revenue optimization. By implementing these strategies and staying abreast of coding updates, healthcare systems can navigate the complex landscape of CPT coding, minimize losses, and enhance patient care.

Sources:

1. The ABCs of Coding Denials: Avoidable, Burdensome, and Costly
2. Potential loss of revenue due to errors in clinical coding during the implementation of the Malaysia diagnosis related group (MY-DRG®) Casemix system in a teaching hospital in Malaysia
3. Over 20 Woeful Medical Billing Error Statistics
4. Who’s Auditing Your Coders? - AAPC Knowledge Center

Feel free to explore more about CORE Medical Revenue Cycle Management on their website: CORE Revenue Cycle Management.