1. Read the notes carefully.
If coders and billers don’t read notes carefully, they might miss a key component that the provider also missed. For example, if the notes say “cleaned ear,” it’s not clear which one. In a circumstance such as this one, either ask the provider for details or see what patient came in for.
2. Query the physician/surgeon if you are uncertain.
Cardiology, eyes and orthopedics can be especially confusing for coders and billers, according to Ms. Morgan, so asking questions could be helpful when dealing with these specialties.
3. Make a cheat sheet.
This document should list all the possible codes that might be used so that it helps you and the providers. “I did this when I worked at an ASC and it was very useful and bills were sent out correctly,” Ms. Morgan said. “For the ASC that I coded/billed for, I created a sheet for the GI physicians to use. It listed all the possible diagnosis codes and surgical procedures they performed. I reviewed prior surgical procedures and from that created this reference guide. I also did it for walk-in clinics. However, this was before computers came into play and medical records became electronic.”
More articles on coding, billing and collections:
Physician argues to eliminate Alaska’s CON law — 4 insights
5 challenges for spine, orthopedic practice billing and coding in 2018
Surgical Notes releases updated mobile transcription app – 7 highlights
