8 Steps to Ensure Efficient Medical Coding for Healthcare Practice

Despite, the advancements in healthcare sector, many healthcare providers still fail to compile error free medical claims. In fact, as per a recent research, nearly 80% of them contain error. Now, the question arises, what to do to fill in these widening gaps? Many experts reveal that approximately 40% errors are due to coding in efficiencies. They are of the opinion that if immediate attention is given to coding then errors can be reduced to a larger extent.

Keeping that in mind we have put forward few important measures for efficient medical coding-

Coherent Documentation:

Improper filling of patient’s information is one of the biggest contributors to coding errors. If the credentials of the patient is not written or noted accurately then professional involved in coding will certainly input the wrong code. That’s the reason why recording correct and detailed information should be given utmost importance.

Detailed and Updated Coding Manual:

Picking out coding guidelines from manuals proposed by CMS and other healthcare regulatory organizations is always a good idea. Coders can frequently use them for the references. But, practitioners should also make sure that the manual is always up-to-date and contains recent trends along with industry practices.

Train the Staff:

Both medical and non-medical staff should be informed and trained about any new updates in coding. Along with the recent discoveries, staff like physicians and others dealing with patients should be instructed to note the disease precisely. Also, it will be great if the doctors and nursing staff are aware about their direct and indirect roles in entering the codes correctly.

Find Error Trends:

A comprehensive study should be done to know the trends of the medical coding mistakes of the past and possible errors which can occur in future. This will help the teams to get rid of the repetitive errors and adopt measures to circumvent possible future errors.

Review of Reports:

Reviewing every report and scans of the patients before sending it for coding is an intelligent thing to do. This gives physicians and nursing staff, a second chance to evaluate the services to be coded and eliminate root-causes of coding error.

Randomly Using Modifiers:

Picking correct modifiers, whether it is developed by AMA or CMS, is a critical phase. Many coders and medical organizations normally do not pay much attention to this, but along with the other steps involved in getting the codes right, this step is equally important. And, this requires better knowledge of National Correct Coding Initiate (NCCI) which the coder can inculcate easily.


Avoiding assumption and guess work is the key here. In case of any doubt about the services incurred by the patient, the coder should immediately confront with the respective staff member. It should be clearly instructed to the coder not to input codes for any unclear, missing or inconsistent information. The organization should make sure that if the service is not documented by the physician it can never be coded by the coder.

Implement EHR System:

EHR system will automate the entire medical billing process will definitely shrink the chances of errors. But, for this the staff should be properly trained to use the automated tools for billing.

The above mentioned tips will go a long way in improving the clean claim rate of your practice. But, if you still have any issues and need any assistance, look no further than OutsourceRCM. By implementing a carefully crafted coding strategy that has been refined over the years, we enable your practice to close the gaps in coding and eliminate future errors.

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