1 PRACTICAL CODING Marsha Massino, RHIT Coding Coordinator, Dept of Medicine

2 Key components for code History Physical Medical Decision Making

3 Choosing the correct code Place/Type of Service Content based ? Time based ?

4 Common problems Undercoding – to be safe Overcoding – not all components present Unclear objective – chief complaint not clearly stated Patient not present at visit No documentation

5 CERT – Comprehensive Error Rate Testing (2004) Type of Error: Insufficient documentation43.7% Non-response29.7% Medically Unnecessary17.2% Incorrect Coding 7.7% Other 1.6% Source - Centers for Medicaid & Medicare Services

6 Top 10 Documentation, Coding and Billing Errors that Can Prevent Physicians From Being Paid 1 No documentation for services billed 2 Missing signatures 3 Always assigning the same level of service 4 Billing of a consult instead of an office visit 5 Use of invalid codes due to use of old resource

7 Top 10 Documentation, Coding and Billing Errors - continued 6 Unbundling procedure codes 7 Misinterpreted abbreviations 8 No chief complaint listed 9 Billing of services included in global fee as a separate professional fee 10 Use of an inappropriate or no modifier for accurate payment of a claims