In Coding
Oct 7th, 2019
Don’t let insufficient documentation lead you astray. How many times has a provider asked you, “What do I need to document to get a 99215?” All too often, medical coders feel they should help their providers understand what elements of documentation are needed to warrant the higher level evaluation and management (E/M) service. Do not ...
Use your job-related pet peeves to initiate better communication in your healthcare organization. Pet peeves are things other people do that annoy you. I’m sure you can think of lots of things your physicians do that get on your nerves. Here’s my top 10 list of a medical coder’s pet peeves, with tips for resolution. ...
Oct 18th, 2017
Working remotely or offsite has become the new normal for coders, making the art of communication more important than ever. But with such a large influx of young coders, it’s difficult for many who have grown up with texting as a primary form of communication to remember to use complete words and sentences. As such, ...
Failing to thoroughly document signs and symptoms, assessments, and treatments of chronic diseases creates a ripple effect of misfortune. First, all relevant codes are not captured; this leads to improper payment (not to mention, an injustice to the patient). The next thing you know, the claim fails a Risk Adjustment Data Validation (RADV) or Office ...
In Coding
Aug 2nd, 2016
When medical documentation is unclear or incomplete, the coder’s job is to query the provider. This can be done verbally or in writing, but not in an email or with a sticky note in the chart. With the introduction of electronic medical records (EMR), best practice is for queries to be in writing via messaging ...