How to Ensure Accurate Medical Coding Practices

With ever-changing reimbursement models, Federally Qualified Health Centers (FQHCs), hospitals, and medical practices face significant risks and potential penalties associated with inaccurate medical coding. To safeguard your organization and maintain compliance, it is essential to implement effective strategies for accurate coding. Below are several recommendations to help you achieve this.

Invest in Education

The accuracy of medical coding is directly tied to the expertise of your coding team. To maintain high standards, it is crucial to provide ongoing education and training for all staff involved in coding. Because medical codes are updated, added, deleted, bundled, and unbundled each year, staying current with these changes is essential. Without continuous education, the likelihood of coding errors increases, which can lead to compliance issues and financial penalties.

Use Detailed Documentation

Comprehensive documentation serves as the primary communication channel between physicians and coding staff regarding patient care. Detailed records enable accurate coding and ensure appropriate reimbursement for your organization. They also help coders confirm codes and provide necessary evidence that care was delivered. Inadequate or inaccurate documentation can delay payments and create compliance challenges. To support your physicians, especially when codes are revised, provide printed materials that outline documentation requirements to promote accuracy.

Perform Regular Audits

Scheduling regular audits is an effective way to monitor and improve coding accuracy. Audits are especially important following code updates or staff changes, as coding responsibilities may be distributed among a diverse group of personnel. This distribution can sometimes lead to inconsistencies. By conducting audits on a routine basis, you can identify areas where additional training or support may be needed to maintain high standards of coding accuracy.

Provide Up-to-Date Coding Resources

Access to the most current medical coding references is vital for accurate coding. These resources should be available both online and in print for easy access. It is also important to archive older annual reference materials in case there are questions about previously coded charts. Additionally, the Centers for Medicare & Medicaid Services (CMS) releases quarterly updates on modified codes, so subscribing to these updates ensures your organization is always equipped with the latest information.

Consider Outsourcing and External Audits

Managing annual changes in medical coding can be overwhelming and costly, especially regarding ongoing training and education. However, maintaining accurate coding is crucial. If your organization lacks the time or financial resources to keep up with these demands, consider engaging outside audit services or outsourcing your coding functions to experts. This approach can help ensure that your organization remains compliant and achieves accurate coding results at all times.