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Seven signs your healthcare practice needs help with medical coding

January 17, 2025 | Daniel Doll

Medical coding can make or break a practice. ARIA Coding Services helps providers keep up with policy changes, guidelines, clinical documentation, and timely reimbursements.

An ARIA specialist assists with a practice's medical coding.

In the complex world of healthcare, accurate medical coding is crucial for ensuring that providers receive proper reimbursement for their services. Unfortunately, many practices struggle with coding issues, which can lead to financial losses and compliance risks. 

Here are seven signs that indicate your healthcare practice may need help with medical coding, along with the associated risks and the importance of addressing these challenges. 

1. Significant amount of medical coding rejections and denials 

Risks: High rates of coding rejections and denials can strain the financial health of your practice. This not only affects cash flow but also increases administrative burdens as staff must often resubmit claims. Persistent denials could lead to decreased business trustworthiness and could even raise red flags with insurance companies. 

Importance: Efficient coding is essential for timely reimbursements. Practices with high denial rates may incur additional costs due to the resubmission of claims and administrative overhead. Addressing coding issues can help streamline workflows, reduce turnaround times for payments, and boost overall revenue. 

2. Lack of certified medical coders on staff 

Risks: Employing untrained personnel for medical coding can lead to severe inaccuracies in billing. Incorrect codes can result in claim denials, compliance issues, and potential legal ramifications. Lack of expertise may also over-rely on outdated knowledge about coding standards. 

Importance: Certified coders have a thorough understanding of coding guidelines and regulations, allowing them to accurately assess documentation and select appropriate codes. Investing in certified coding professionals or partnering with ARIA Coding Services can improve the quality of coding in your practice, reducing errors and optimizing revenue cycles.

Identifying the signs that your healthcare practice needs coding assistance is the first step in protecting your revenue and ensuring compliance in medical billing.

3. Providers unaware of medical coding documentation guidelines 

Risks: Accurate medical coding demands comprehensive and precise documentation. When providers are unaware of the required documentation guidelines, they risk missing essential details that impact coding accuracy. This oversight can create inconsistencies, leading to denials or audits. 

Importance: Educating providers on documentation guidelines and best practices ensures proper representation of the services rendered, allowing for appropriate reimbursement. Training sessions, workshops, and access to resources can empower providers to maintain accurate records, promoting a culture of compliance. 

4. Providers unfamiliar with 2021 Office/Outpatient and 2023 E&M guidelines 

Risks: Recent revisions to evaluation and management (E&M) guidelines have changed how visits are documented and billed. If providers are not familiar with updates such as the 2021 Office/Outpatient and 2023 E&M guidelines, it can lead to inappropriate billing, misinterpretation of service levels, and non-compliance with regulations. 

Importance: Staying updated on coding guidelines is essential for maximizing reimbursements. Familiarity with recent updates enables providers to accurately document the time involved and complexity of visits, ensuring that practices are compensated appropriately for the level of care provided. 

5. Failed audits by third parties/payers 

Risks: Failing a medical coding audit can result in financial penalties, recovery of payments made, and even legal action. Frequent failures indicate underlying issues in coding practices, compliance strategies, and documentation procedures. 

Importance: Regular audits and compliance checks are crucial for identifying coding inaccuracies and potential risks. Proactive measures, such as an internal coding audit and ongoing training, can help practices improve their coding processes and ensure alignment with industry standards, safeguarding against costly penalties.

Expert assistance with medical coding

Medical coding can make or break a practice. ARIA Coding Services helps providers keep up with policy changes, guidelines, clinical documentation, and timely reimbursements.

6. Consistently paid for a lower level of visit than billed 

Risks: If a practice consistently receives payments for lower-level visits than what was billed, it may indicate a mismatch between the services rendered and documented. This not only affects revenue but raises concerns about the quality of coding and documentation practices. 

Importance: Accurately reflecting the service level provided in billing is essential for fair compensation. Practices can understand the root cause of the discrepancies by conducting internal reviews to identify patterns. This leads to better documentation and improved billing outcomes. 

7. Payers ask for refunds after reviewing documentation 

Risks: If payers are requesting refunds after claims have been paid, this signifies a discrepancy between the coding billed and the supporting documentation. Such requests can disrupt financial stability, undermine provider-payer relationships, and signal systemic issues within the coding and documentation processes. Pre-payment audits may be instituted by the payer which further delays payments. 

Importance: Implementing preventative measures, like robust coding checks and audits, can significantly reduce the likelihood of payer refunds. By addressing these issues, practices can foster trust with payers, ensuring better long-term financial health. 

Expert medical coding services are available 

Identifying the signs that your healthcare practice needs coding assistance is the first step in protecting your revenue and ensuring compliance in medical billing. By recognizing these warning signs and taking proactive measures to address them, practices can enhance their coding accuracy, reduce financial risk, and ultimately provide better care for patients. 

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