Mastering Medical Coding Compliance

Merely mentioning coding compliance to a physician may produce responses ranging from an eyeroll to dread and anxiety. The entire coding process is often seen as a necessary evil. After all, doctors don’t spend years in training to become coding experts. Many physicians may not regard coding as their responsibility or believe that they don’t have sufficient time to document everything at the time of care. Yet an Ingenious Med survey found that over 60 percent of healthcare leaders said their coders spend over 10 percent of their time tracking down information from physicians. A similar percentage said that missing charges were their most important charge capture challenge.

The coding process is fraught with risk – both from compliance penalties due to improper coding or overcoding and, more important for practice viability, underpayment due to undercoding.

jenga blocks showing risk

CMS and other payers have developed regulations designed to prevent fraud and abuse by healthcare providers. Red flags include data that indicates potentially questionable billing practices, which can trigger an audit that may result in stiff fines. While CMS temporarily halted audits starting March 30, 2020 due to the COVID-19 pandemic, the agency plans to resume them on August 3, 2020.

This situation creates a symbiotic relationship between providers and coding departments. Without cooperation from both parties, bills will not be accurate and healthcare organizations will risk external audits and substantial penalties. But if providers have the right tools to help them code appropriately, then they can help the entire healthcare organization – and optimize their take-home pay.

How can this process benefit both physicians and healthcare organizations? By addressing three areas of the coding process: workflow efficiency, compliance and physician work relative value unit (wRVU) improvement. Of these three components, the greatest risk comes from compliance.

Building Medical Coding Compliance into the Process

Ingenious Med built MasterCoder to help care providers select the correct evaluation and management (E&M) codes at the point of care. When enabled, MasterCoder guides providers through the criteria needed to meet appropriate E&M service levels. While MasterCoder does not replace the need for doctors and coders to correctly chart and document charges, it is an effective tool to increase coding accuracy and optimize coding efficiency.

Unlike EHR “black box” systems, a purpose-built third-party solution enables charge coding immediately following care delivery, regardless of location across the care continuum. This provides the greatest coding accuracy and least risk of missing charges. The farther a clinician gets from seeing a patient, the greater the chance for errors. That problem is compounded when clinicians can’t enter coding at the point of care in settings such as skilled nursing facilities (SNFs) and home health visits.

coding compliance via mobile ingenious med app

EHR systems often code using a single mouse click without process transparency, leading to inaccurate coding and the potential for missed charges. With Ingenious Med’s MasterCoder, providers who omit a service are prompted to add it, increasing coding accuracy and creating the opportunity to bill for a higher level of service.

MasterCoder has been proven to improve the three-part issue from improper coding by:

  • Greatly improving coding consistency at the point of care, saving coders valuable time.
  • Minimizing errors that result in over or undercoding on an insurance claim, preventing red flags for external audits and protecting against costly compliance penalties.
  • Increasing the overall dollars per wRVU across an organization. According to Ingenious Med records, bills using MasterCoder resulted in 12 percent higher RVUs than those not using it.

MasterCoder is not a cure-all for inefficient or inaccurate coding. It also does not replace scheduled, periodic internal charge capture audits. Consistent use of the MasterCoder tool can yield incredible results in mitigating losses from chronic undercoding and code compliance risk from overcoding.

For more information about MasterCoder and other features of Ingenious Med, please speak with a representative at 770.799.0909 or request a demo today at