Gems Of Medical Coding That Can Optimize Reimbursement

Audit risks, payer requests, and denials are just a few of the issues that healthcare providers face—issues that ultimately impact their bottom line and ability to provide proper care for their patients. It is crucially imperative to ensure that medical records are properly documented to avoid these problems. Outsourcing your - medical coding functions to an expert provider can help you achieve exactly that. However, you and your team still need to be familiar with the following medical coding gems that can help optimize reimbursement and overall revenue:

1. Be careful about Electronics Health Records (EHR) templates that pre-populate fields with information. It pays to be vigilant and ensure that fields are never wrongly populated when documenting care in EHR. Note that pre-populated EHRs can sometimes denote that tests were performed even when they actually weren’t.
2. Beware of the risks of certain Evaluation and Management (E/M) pitfalls when using EHRs. The process of identifying a visit’s E/M code is automated by EHRs, and this is where problems may arise. Did you create your own template? Don’t assume that a particular level of E/M services is automatically supported by specific diagnoses. Templates tend to make it easier to record higher levels even without medical necessity, and this attracts the inspection of auditors.
3. Pay close attention when using the copy-and-paste functionality of the EHR. Failure to check whether the information is applicable to the current visit may cause problems. Improper verification and pasting in the wrong code may lead to the unintentional submission of false claims.
4. Use the correct E/M codes. The E/M codes that are used must reflect the nature of the initial symptoms or presenting problems. According to coding experts, it is also crucial for physicians to update the E/M levels for the same patient as needed. For instance, a patient who came in with a severe condition may get better over time, so the codes used should also be updated to reflect this development.
5. If you want to bill prolonged services, it is advisable that you document the tasks that you have performed to prolong that care. These claims are reimbursed by Medicare and other payers if documentation shows proof of the time that you have spent and the things that you have done to render the service.

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