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When An EMR Coding Algorithm Isn't Enough: How Using Certified Medical Coders Can Make A Positive Impact On Your Practice Revenue

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Medical billing and coding are vital components of a practice's financial success. Accurate and timely reimbursement for the services provided is critical, and practices have turned to coding algorithms as a means to manage the complexity and time-consuming nature of the process. Unfortunately, relying solely on coding algorithms is often costing medical practices money and may put practices at risk for documentation compliance issues. In this blog post, we will examine the advantages of using certified medical coders to provide a more effective solution.

Certified Coders Accurately Evaluate Nuance

Coding algorithms are automated systems that generate encounter codes from data entered by clinicians during a patient encounter. The algorithms are usually designed to produce a CPT code(s) based on the selection of boxes/criteria built within the EMR. The CPT code(s) is dependent on the provider accurately choosing/clicking on the correct criteria/boxes. Per AMA, the thought process of the provider should be documented in the patient note to support the medical decision-making. Providers most often use free text to document this. While these algorithms can identify CPT code(s) based on specific criteria entered or boxes checked, they completely lack the ability to read the free text in the note to ensure that the CPT code(s) generated is accurate, compliant, and complete.
Certified coders are well-versed in medical terminology, anatomy, and physiology. They are trained to read a chart to analyze ALL the information provided during the encounter through a critical lens to ensure accurate coding. For example, if a patient's medical record is incomplete or unclear, a certified coder can reach out to the healthcare provider to request additional information, ensuring that the coding accurately reflects the patient's diagnosis and treatment.

Certified Coders Adapt Faster to Changing Requirements

Coding rules and guidelines frequently change, and coding algorithms may not be updated at the same pace to reflect these changes. It is not unusual for the developers to sometimes take days or even a few weeks to update the algorithms. This in turn may cause unnecessary delays in payments and avoidable denials.  Certified coders are required to be up to date on the changing rules and requirements and will be able to immediately implement any changes to ensure proper compliance, therefore, saving time and money for the practice.
Certified coders can also identify areas where a practice may be losing revenue and make recommendations on how to improve revenue. Coders often provide feedback on how to improve the overall medical billing and coding process to maximize revenue. Working with certified coders can help streamline the medical billing and coding process, reducing errors and improving efficiency, saving medical practices time and resources while ensuring accurate coding and timely reimbursement.

Certified Coders Protect Practices During an Audit

A certified coder's expertise is particularly crucial when it comes to audits, where practices must demonstrate proper record-keeping, accurate coding, and adherence to compliance regulations. During an audit, a certified medical coder's ability to review medical records and communicate with healthcare providers can be invaluable in protecting a practice.  A certified coder will always consider the medical necessity of the visit and ensure the documentation supports the choice of a CPT code(s). This is vital in any audit rebuttal.

Certified Coders Provide Invaluable Training, Education, and Documentation Feedback

One of the most important contributions of a certified coder is the documentation training and education that they can provide to clinicians. Training and education will help providers document notes that reflect their work and are an accurate representation of the patient’s acuity. It is important to remember that patient charts are medico-legal documents and an important tool in the continuity of patient care.
In addition to general documentation education and training, certified coders can also provide immediate feedback to the provider when they come across documentation issues as they code. This can help prevent compliance issues since the provider can be queried and necessary corrections can be made before the encounter is billed.
The amount of money a certified medical coder can save a private medical practice can vary greatly depending on factors, such as the size of the practice, the number of physicians, the complexity of the coding required, and the efficiency of the coding process. However, studies have shown that having an experienced certified medical coder can lead to significant cost savings for a practice. According to a survey conducted by the American Academy of Professional Coders, practices with a certified coder on staff had a 6.4% higher revenue capture rate and a 17.6% reduction in claims denial rates compared to practices without a certified coder. This can translate to a practice potentially saving thousands of dollars per year.
In conclusion, healthcare practices that rely solely on coding algorithms are missing out on revenue opportunities and losing money due to coding errors, outdated coding algorithms, and lack of expertise. In contrast, certified coders provide accurate, expert coding, adapt to changes in coding regulations, streamline the billing and coding process, identify coding errors, and provide training and education to improve documentation, coding accuracy, and efficiency. By working with certified coders, practices can protect their revenue and ensure timely and accurate reimbursement for the services provided.
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