Medical coding turns the documentation of a visit into the standard codes that claims rely on. It sits between clinical documentation and billing, which is why a coding workflow touches both.
Where coding fits
Coding follows documentation and comes before claim submission. The codes assigned have to agree with what was documented, so problems in either direction show up as questions: documentation that does not support a code, or a service that is documented but not yet coded.
Questions to ask about your workflow
- Who assigns codes, and how are they trained on changes to the code sets?
- When documentation is unclear, how is the question sent to the provider, and how is the answer recorded?
- How long does it take, on average, for a visit to be documented and coded?
- Where are recurring documentation issues recorded?
- Who reviews coding that has been the subject of a denial?
Keeping the clinical record intact
A coder works from the documentation and does not change it. When something is missing or ambiguous, the right step is a query to the provider who wrote it. Keeping a simple log of queries and answers helps the practice see which kinds of documentation gaps come up most often.
Working with outside support
Some practices share coding work with an outside team. In that case it helps to agree in writing which guidelines apply, how queries reach providers, how quickly they are expected to be answered and how coding questions are reported back, so that the arrangement fits the way documentation already moves through the practice.
Coding rules and payer requirements change over time, so a practice's workflow benefits from a regular review, as well as from attention to individual claims.
This article is general information about healthcare business operations. It is not medical, legal or financial advice.
