Foster a positive relationship between providers and coders
This is likely the most important step in setting the course for best practices. Certified coders have a specific skill set that includes an understanding of anatomy and physiology, pharmacology, and medical terminology. Setting up a team that consists of coders, physicians, and department heads, who meet regularly to discuss obstacles encountered and
Demand the best
Coding professionals, certified or otherwise, must be well-trained and able to weed through vast amounts of information to find what is accurate and substantiated. Now more than ever, organizations should be evaluating their coders to ensure that they have the experience it takes to be the best at their jobs. Certified coders are preferable; however, an organization can find a valuable asset in a coder who can not only assign codes, but reiterate a logical line of thinking in their coding choice, cite coding guidelines, and use only reputable sources.
Put it in writing
Despite the fact that coding seems to be black and white on the surface, there are many gray areas. Even when published guidelines exist, there may be a difference of opinions between fiscal intermediaries and payers on the correct interpretation of the guidelines. Providers and organizations have the choice about which to follow, and can even follow both, which is why it’s important to put into writing which will be followed. This ensures that both providers and coders know what they need to do, and that quality assurance checks are fair and consistent.
A well-written coding best practices plan should address not only which E/M guidelines should be followed, but also includes items such as the query process, guidelines for adding addendums to records, timelines for dating and signing records, and how to react to external audit requests to name a few. Written plans provide a clear set of instructions for physicians, coders, quality assurance analysts, and compliance team members. Additionally, they provide added benefits and resources when dealing with external auditing organizations.
Provide education and resources
Education for all levels of staff is essential. Every year, there are numerous changes, additions, and deletions to CPT. Each year, professional organizations provide in-depth guidance on these changes, while organizations such as the AMA and CMS provide written guidance on LCD’s and NCD’s. Resources such as CPT, HCPCS, and ICD-9 (soon to be ICD-10) books must be updated regularly. EHRs must be regularly updated to reflect these changes to ensure that data from this resource is accurate.
Monitor for quality, teach new concepts and reinforce good behaviors
The quickest way to ensure that coding is up-to-speed is to perform regular quality checks. The use of auditing - even in small quantities - can provide insight to the documentation practices of physicians, nurses, and other clinical staff.
Documentation reviews can detect issues such as lack of signed orders, missing dates, insufficient documentation to support specific codes, and lack of specificity for diagnosis codes -all of which can have a potentially negative impact on compliance and revenue. Coding reviews ensure that analysts are capturing the data required for a clean claim, and that coders are capturing all procedures.