8 Tips for a Clean Claim: How a Medical Coder Tells the Accurate Story of the Visit



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Written by Misty Smith, CPC, COSC, Billing and Coding Expert from Bluegrass Orthopaedics

Medical coders are the storytellers of the revenue cycle: they have the responsibility of telling the story of the patient's visit to the insurance company. Through solid knowledge of the coding systems (CPT, ICD-10 and HCPCS) a coder translates the care provided into a language the insurance company recognizes. Before hitting send on a claim, here are eight important tips to consider when making sure the insurance company gets the complete and accurate story of the visit so you can avoid unnecessary denials. 


1. Consult up-to-date coding books and references. Adhering to the correct and current coding guidelines is imperative as medical coding is an ever evolving and changing profession. 

2. Analyze medical records to determine the documentation is complete and accurate. If a right shoulder injection is marked on the charge slip, but the medical record states the left shoulder, query your provider. 

3. Sequence CPT codes according to RVU and append the most specific ICD-10 to each one in order of priority to support medical necessity. 

4. Append appropriate modifiers when necessary. 

     Example: If your provider is specific to say they injected the MP joint of the left ring finger, append the modifier F3 rather               than the modifier LT for left, to report the highest level of specificity. 

5. Determine and check current NCCI edits to avoid unbundling denials. 

     Example: Fracture manipulation includes the FIRST splint application and the splint is not separately billable, the                               manipulation and splint application are reported with a single code. 

6. Carefully review to account for all services provided this will help to prevent under coding. 

     Example: Reporting a limited ultrasound when a complete ultrasound was performed. Be sure to capture the full extent of             services provided. 

7. Stay away from up-coding. Do not incorrectly assign a code that reflects a more severe diagnosis or treatment that would result in a higher reimbursement. Communicate with your providers when you believe their documentation does not support the level of service chosen to be billed. 

8. Put a plan in place that will help identify the claim errors that result in denials. Communicate with your revenue team and providers regularly. Track and review workflow claim reports to make adjustments as needed to the standard processes and retrain revenue and clinical staff when appropriate to address the coding or documentation errors. 

The level of medical coding system knowledge used to review medical records and assign codes are uniquely valuable skills that should not go overlooked. Medical coders that can relay the accurate and complete story of the patient visit to the insurance company are integral to the revenue cycle of your organization. By closely adhering to these eight pro-tips, you can receive fewer denials, increase cash flow, and accelerate reimbursement in no time. 


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