Fundamental Guidelines for Medical Coding

Medical coding the profession that facilitates the medical billing process and the collections for healthcare facilities is a critical and inevitable process in the healthcare facilities. The medical coding process is not only required for billing purposes but it also helps government authorities to understand and track statistics about various ailments and diseases that affect people. This process involves taking reports from doctors with details of a patient’s condition, the diagnosis, medication or services provided and translating them into alpha-numeric codes that are universally acceptable.

The medical coding jobs require that a coder assigns accurate codes consisting of numerals and letters that are unique to every kind of diagnosis, symptom, and treatment procedure. Healthcare facilities need services of experienced coders with exceptional expertise as the coding process is one of the most influential factors in securing insurance reimbursements. Professionals in medical coding jobs need to be highly knowledgeable in different types of code sets such as – ICD -10 codes, HCPCS codes, and CPT codes. Here are certain fundamental rules and guidelines that every medical coder must be aware of.

Follow documentation: The first and foremost requirement of the medical coding process is to maintain consistency with the physician documentation or medical record. Coders should never forget the golden rule – ‘Only code what is documented’. It is important for the medical coding companies to educate their coders that they should assign codes only to what is mentioned in their source document.

Follow correct order: Coding in correct order takes as much significance as accurate coding. Coders should be highly attentive while assigning codes as the placement of a number or letter in the code changes the whole context of the ailment or treatment provided.

Follow NCCI and MUE guidelines: Different insurance payers along with Medicare and Medicaid have different guidelines to be followed that are to be strictly followed. Coders have to report units of service on the basis of NCCI and MUEs so as to avoid reporting multiple services or procedures that should not be billed together.

Modifiers should be used appropriately: Modifiers are codes that consist of two digits involving numbers, letters or a combination of both. These are used with some CPT and HCPCS codes to furnish additional information about the service or procedure performed on a patient.

Follow the coding updates: Healthcare industry is one that sees multiple changes and updates from time-to-time. To ensure that the accurate codes are assigned, medical coders have to stay up-to-date on various aspects related to the healthcare industry in general and coding process and its guidelines in particular.

The financial well –being of a healthcare provider depends on its ability to collect the payment accurately on time and this collection process highly depends on the coding and billing processes. It is important for healthcare facilities to hire the right medical coding companies to do this job for them.