A Brief Guide on Documentation and Coding

A provider has the responsibility for making sure that the correct level of service was provided and the proper code was used for billing. This duty cannot be passed on to someone else. The physician provided the service, they have to decide what to bill. They know better than anyone what services were provided.

The first step is to decide what the diagnosis is. An ICD-9 code is then used to describe the diagnosis (soon to be ICD-10). The next step is to code the treatment by using a CPT code. Which describes the treatment the patient received or the visit that took place.

A common misconception is that downcoding can help avoid audits. Unfortunately, not only is that not true but it cheats the physician from receiving payment for services they deserve. So it’s important for providers to document their services accurately and keep track of the time they have spent with the patient in order to be able to bill for the proper services rendered.

Some physicians are hesitant to use a new CPT code because they rationalize that the insurance company won’t pay for it. It’s just the opposite, if the insurance company sees that a certain code for a service is not being used often, they may be less likely to cover it. If the physician feels this way, for their sake it’s important to have good documentation to justify using a new code or any code for that matter.

It’s important to evaluate what sort of impact your coding will have on your patients. In some cases, if a particular code is not paid for, the charge will be passed onto the patient. Billing a particular CPT code or “-25″ modifier may be justified, but it also could cause a problem if a large portion of your practice complains about having to be responsible for these charges.

A practice that keeps up to date with coding changes and who follow proper coding procedures will do well overall. Changes happen all the time and if the person handling the physicians billing is not up to date, it could cost the practice a lot of money. Attending coding seminars, commercial resources online or subscribing to newsletters is helpful in keeping up with the changes. Some practices or healthcare providers who are in a large group still have to be mindful of coding procedures and not just rely on those who are doing the actual billing.

Physicians should have clear knowledge and understanding of billing and coding practices in order to be able to be the most accurate and precise as possible. Having good communication with the insurance biller is also key to correct and accurate billing.

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