Anesthesia Coding Alert

Heads up: Focusing on certain areas can help keep denials at bay.

Every coder knows that the best way to steer clear of denials is by working with providers who are documentation all-stars. Being on the same page with your providers helps minimize documentation errors, which can lead to higher reimbursement. 

Brush up on a few basics to ensure the providers and coders in your group are helping each other reach those rewards.

Focus on Notes and Codes

Messy or vague charting leaves coders to decipher illegible documentation with the tough job of translating these notes into Medicare claims. That initial breakdown between providers and coders can set you up for failure.

"Documentation is an essential factor in the success or failure of the coding process," says Nikki N. Taylor, MBA, COC, CPC, CPMA, an auditor with TCI Consulting & Revenue Cycle Solutions, "Provider documentation must provide a clear and complete picture of what occurred during the visit which will allow the coder to properly code the case."

Unfortunately, mistakes still do happen, but ensuring that your notes are metaphorically bulletproof helps to eradicate the types of common errors found in the 2016 CERT report. 

Take Your Time With Each Claim 

Under some healthcare regimes the pace can be extremely fast, and coders feel obliged to make shortcuts to meet the time constraints. This is when omissions and abbreviations from both provider and coder can lead to audits and Medicare payment reversals.

"From experience, providers will often omit key information from the medical record documentation and assume that the person reading the documentation does not need a detailed account of the visit," Taylor says. Oftentimes, coders will enquire about the mixed messages, but sometimes they don't, and that can lead to trouble.

Conduct an Internal Audit

Healthcare has become extremely complicated over the past 20 years, and in order to stay fiscally sound and remain in compliance with the necessary standards, practices and hospitals must check themselves regularly. Both internal and external audits done annually allow you and your staff to see where you need improvement.

Your results might show that your practice continually makes coding errors by using the wrong modifiers or drops the ball when it comes to enforcing HIPAA. 

Taylor recommends that providers take advantage of auditing as a tool to overcome "poor coding habits and poor documentation." She says that regular auditing helps with the following: 

• Rectifies coding controversies.
• Measures the quality of your patient care. 
• Reforms staff compliance issues. 
• Promotes the need for education of both providers and coders.
• "Assists with charge capture."
• Provides you with the data necessary to combat "government scrutiny."

Tip: Take a look at your EHR or engage a certified health IT vendor about documentation auditing. Many EHRs contain tools for performing an electronic documentation audit, which will give you a heads up on what your practice needs to work on to meet CMS standards.