Wiki Coding Review Requirements

[sziapao]

Hello,

Does anyone have any documentation (CMS) where certified coders are required to review every chart the physicians? code before it is billed? Is this considered a best practice or is it better to perform retrospective auditing?

Thank you,

Paola T.

 

[MnTwins29]

CMS does not dictate WHO must assign codes - just that they are supported by documentation and are medically necessary. As for having a coder review every record, that would be a best practice if your practice/facility. Retrospective auditing can help identify your weaknesses and provide guidance on where to improve your processes.