At Medical Billers and Coders (MBC), we provide medical coding and billing services to help healthcare providers and coding teams adapt to evolving regulations, reduce denials, and improve revenue cycle efficiency.

Key CMS 2025 Changes in Medical Coding

1. ICD-10-CM Code Updates

• CMS has introduced over 400 new ICD-10-CM codes in 2025, including updates for:

• • Neurological conditions (e.g., expanded stroke classifications)
  • Cardiac disorders (e.g., detailed heart failure codes)
  • Infectious diseases (e.g., post-COVID complications)

MBC ensures accurate diagnosis code selection to prevent claim denials.

2. CPT and HCPCS Code Revisions

• Dozens of new CPT and HCPCS codes reflect changes in:

• • Telehealth & remote patient monitoring
  • AI-assisted diagnostic procedures
  • New surgical techniques & procedures

MBC keeps coding teams updated on the latest procedural codes.

3. Stricter E/M Coding and Documentation Requirements

• E/M services (99202-99215) now focus more on Medical Decision Making (MDM) rather than history and exam components.
• Time-based coding requires precise documentation of total encounter time.

MBC ensures compliance with the latest E/M guidelines to avoid underpayments.

4. Greater Scrutiny on Modifier Usage

• Modifiers 25 (E/M with a procedure) and 59 (distinct procedural service) are key audit targets.
• CMS now requires stronger justification for their use.

MBC ensures proper modifier application to reduce audit risks.

Medical Coding Challenges & Solutions in 2025

1. Increasing Denials for Incorrect Code Selection

• Errors in ICD-10 and CPT coding leading to claim rejections.
• Payers scrutinizing high-level E/M codes.

MBC Solution:

• Regular coding audits to ensure accuracy
• Training coders on payer-specific guidelines

2. More Audits & Compliance Risks

• CMS & commercial payers increasing post-payment reviews.
• Heavy penalties for improper documentation.

MBC Strategy:

• Proactive compliance checks before claim submission.
• Ensuring all documentation meets audit-proof standards.

3. The Rise of AI in Medical Coding

• AI-assisted coding can lead to miscoded claims if not reviewed properly.
• Physician notes often lack necessary details for AI-driven coding.

MBC Approach:

• Human expertise combined with AI to ensure accuracy.
• Educating providers on best documentation practices.

MGMA Benchmarks for Medical Coding in 2025

To stay competitive, medical coding teams must track key performance metrics:

MetricMGMA Benchmark

Coding Accuracy Rate >95%

Claim Denial Rate <10%

Days in Accounts Receivable (AR) <30 days

MBC helps practices exceed industry benchmarks through expert coding management.

FAQs

Why Choose MBC for Medical Coding in 2025?

• 25+ years of experience in medical coding & billing
• Dedicated account managers for personalized support
• Compliant with CMS, AMA, and payer-specific guidelines
• System-agnostic – We work with all EHR & coding platforms
• Proven track record of reducing claim denials

Want to optimize your medical coding process?

Schedule a consultation today at 888-357-3226!

The post Medical Coding in 2025: Key Changes from CMS Every Coder Should Know appeared first on Medical Billing and RCM Blogs.

At MBC, we apply that same level of customization to your medical billing and coding.

Each healthcare specialty has its own complex billing requirements, and every practice has distinct objectives.

That’s why we don’t just handle your billing; we customize our solutions specifically for you. Our team of experts ensures that every claim is submitted accurately, timely, and in compliance with industry regulations.

You’re unique, and your medical billing and coding should be too.

Why Choose MBC? Because Your Practice Deserves More Than Standard Medical Billing

1. Customized Medical Billing Solutions

Whether you run a small clinic or a large, multi-specialty practice, MBC offers tailored medical billing and coding solutions designed to address your specific needs. We focus on your unique challenges, payer mix, and coding preferences to ensure maximum reimbursement for every service.

2. Specialty-Specific Expertise in Medical Billing

From OB-GYN to Dermatology, each specialty comes with its own coding intricacies. Our team is trained in a wide range of specialties, ensuring your medical billing and coding is handled by experts who understand the unique coding requirements of your field.

3. Personalized Attention for Medical Billing and Coding

We provide dedicated support and one-on-one attention to make sure your medical billing and coding process is seamless. You’ll have direct access to our specialists, who are committed to helping you meet your financial goals while minimizing billing errors and claim denials.

Unique Challenges? We Provide Unique Medical Billing Solutions

1. Facing High Claim Denials?

Denied claims can drastically affect your revenue. We use proactive denial management strategies tailored to your practice’s payer mix and claim history to minimize denials and ensure faster reimbursement.

2. Need Help with Regulatory Compliance in Medical Billing?

Staying compliant with changing healthcare regulations can be overwhelming. Our team ensures your medical billing are up to date with the latest HIPAA, Medicare, and insurance guidelines to keep your practice safe from penalties.

3. Want to Improve Cash Flow with Efficient Medical Billing?

We streamline your medical billing cycle to reduce claim rejections and shorten payment delays. Our solutions are designed to keep your cash flow steady, so your practice can thrive.

Your Practice is Unique, So Should Your Medical Billing and Coding

Why rely on outdated, generic billing methods when you can have MBC’s customized medical billing and coding services? From accurate coding to fast, seamless claim submission, we take care of the details so you can focus on patient care.

Your success is our priority. That’s why we’re committed to providing you with a unique, personalized approach that aligns perfectly with your practice’s needs.

Experience the Difference with MBC’s Unique Medical Billing

At MBC, we recognize that every healthcare practice is different. Let us handle your medical billing with the expertise and care it deserves. Our solutions are tailored to ensure your practice is optimized for maximum revenue and compliance.

Schedule a Consultation Today – Discover How MBC Can Tailor Your Medical Billing and Coding to Your Practice’s Needs.
Call 888-357-3226

With MBC, your billing isn’t just another task – it’s a unique solution designed for a unique practice. You’re unique. Your medical billing should be, too. Let us handle it, the unique way.

FAQs

1. What is Medical Billing and Coding?

Answer: Medical billing and coding is the process of translating healthcare services into standardized codes and submitting them to insurance companies for reimbursement. Medical billers handle the submission and follow-up of claims, while medical coders assign specific codes to each diagnosis and procedure.

2. How Long Does it Take to Process Medical Billing Claims?

Answer: The time to process a medical billing claim varies depending on the complexity of the services provided and the responsiveness of the payer. On average, claims can take anywhere from a few days to several weeks. At MBC, we streamline the process to ensure faster submissions and reduce delays.

3. How Do Medical Billing Companies Help Reduce Denials?

Answer: Medical billing companies like MBC help reduce denials by ensuring accurate coding, timely submission of claims, and proactive denial management strategies. We carefully review claims for potential errors and resubmit denied claims quickly to avoid revenue loss.

4. What Are the Benefits of Outsourcing Medical Billing and Coding?

Answer: Outsourcing medical billing and coding can save time, reduce administrative burdens, and increase revenue for healthcare providers. Professionals like MBC handle the entire billing cycle, freeing up your team to focus on patient care while ensuring claims are processed efficiently.

5. How Can I Improve Cash Flow with Medical Billing?

Answer: Improving cash flow through medical billing involves submitting clean claims, reducing denials, following up on unpaid claims, and ensuring compliance with payer guidelines. MBC provides customized solutions to optimize your billing cycle, ensuring faster payments and consistent cash flow.

The post You Deliver Personalized Care – We Deliver Personalized Medical Billing and Coding appeared first on Medical Billing and RCM Blogs.

Understanding ICD-11

ICD-11 is the latest edition of the World Health Organization’s (WHO) International Classification of Diseases. It serves as a standardized system for classifying diseases, conditions, and other health-related issues, providing a common language for healthcare professionals worldwide. While ICD-10 has been in use in the United States for several years, the transition to ICD-11 is necessary to keep up with global healthcare standards.

The Importance of ICD-11

• Improved Accuracy: ICD-11 offers a more detailed and precise coding system than its predecessor. It includes a broader range of diseases and conditions, allowing for more accurate diagnoses and treatments.
• Global Standardization: ICD-11 facilitates international collaboration and data exchange, ensuring that healthcare information is standardized across borders. This is crucial in an era of global health challenges.
• Enhanced Clinical Documentation: Transitioning to ICD-11 encourages healthcare providers to improve clinical documentation. Accurate coding requires detailed and specific patient records, which can lead to better patient care and outcomes.

Preparing Your Healthcare Organization for ICD-11

• Assessment and Planning: Start by assessing your organization’s current ICD-10 compliance. Identify areas that need improvement or training. Develop a comprehensive transition plan that outlines timelines, responsibilities, and resources required for the transition to ICD-11.
• Educate Your Staff: ICD-11 is a significant change from ICD-10, and it is important to make sure that all of your staff members who use ICD codes are properly trained on the new system.
• System Upgrades: Ensure that your Electronic Health Record (EHR) and billing systems are ICD-11 ready. This may require software updates or system replacements. Conduct rigorous testing and validation of your systems to guarantee seamless integration.
• Clinical Documentation Improvement (CDI): Emphasize the importance of accurate and detailed clinical documentation to support ICD-11 coding. Implement CDI programs to enhance the quality of clinical notes and medical records.
• Compliance Audits: Regularly audit your coding and billing processes to identify and rectify any non-compliance issues. Engage third-party auditing services, if necessary, to ensure objectivity.
• Staff Resources: Evaluate your staffing needs for ICD-11 compliance. You may need to hire additional coders or consultants to assist with the transition. Establish a dedicated ICD-11 compliance team to oversee the process.
• Communication and Collaboration: Maintain open communication with staff and stakeholders throughout the transition process. Collaborate with payers, regulatory bodies, and professional organizations to stay informed about updates and guidelines.
• Testing and Transition: Conduct thorough testing of ICD-11 coding within your organization before the official transition. Plan a phased transition to minimize disruptions to patient care and billing processes.

Preparing your healthcare organization for ICD-11 compliance is a complex yet essential undertaking. It’s not just about coding; it’s about ensuring accurate diagnosis, effective treatment, and adherence to global healthcare standards.

By following the steps outlined in this article and seeking support from experienced medical billing partners like Medical Billers and Coders (MBC), you can navigate this transition successfully.

Stay committed to continuous improvement and compliance to provide the highest quality care to your patients while remaining in step with the evolving healthcare landscape.

Medical Billers and Coders (MBC) is here to Help

Medical Billers and Coders (MBC) is a leading medical billing company that can help you prepare for ICD-11. We offer a variety of services, including ICD-11 readiness assessments, ICD-11 coding and billing support. If you are not sure where to start, or if you need help with any aspect of ICD-11 implementation, please contact MBC today.

We are here to help you make the transition to ICD-11 as smooth as possible. Contact us at 888-357-3226 / info@medicalbillersandcoders.com to know more.

FAQs:

1. What is ICD-11?

ICD-11 is the latest version of the International Classification of Diseases, providing a standardized system for coding diseases and health conditions globally.

2. Why is transitioning to ICD-11 important?

Transitioning to ICD-11 enhances accuracy in coding, improves clinical documentation, and aligns U.S. healthcare practices with global standards.

3. How can healthcare organizations prepare for ICD-11 compliance?

Organizations should assess their current ICD-10 practices, educate staff, upgrade systems, and implement clinical documentation improvement programs.

4. What role does staff training play in the transition?

Proper training is crucial, as ICD-11 represents a significant change from ICD-10, ensuring staff can accurately use the new coding system.

5. How can Medical Billers and Coders (MBC) assist in this process?

MBC offers readiness assessments and support for coding and billing under ICD-11, helping organizations navigate the transition smoothly.

The post Preparing Your Healthcare Organization for ICD-11 Compliance appeared first on Medical Billing and RCM Blogs.

This article explores the significance of code systems in healthcare and highlights the benefits healthcare providers can gain by utilizing professional medical coding services, such as those offered by Medical Billers and Coders (MBC).

Understanding Code Systems in Healthcare

Code systems in healthcare are standardized sets of alphanumeric codes that help classify medical conditions, procedures, medications, and other relevant data. These codes provide a common language for healthcare providers, payers, and regulatory bodies to communicate effectively.

Two prominent code systems widely used in the medical industry are the International Classification of Diseases (ICD) and the Current Procedural Terminology (CPT).

• The ICD code system, currently in its 10^th revision (ICD-10), classifies diseases, injuries, and causes of death. It enables healthcare providers to accurately document patient diagnoses and facilitates the identification of epidemiological trends for public health purposes.
• On the other hand, the CPT code system, maintained by the American Medical Association (AMA), is used to describe medical procedures, services, and tests. CPT codes allow healthcare providers to bill for their services accurately and ensure proper reimbursement from insurance companies.

The Role of Medical Coding in Healthcare

Accurate and consistent medical coding is vital for various aspects of healthcare operations. Let’s explore into the key roles of medical coding:

• Precise Documentation and Communication: Medical coding ensures precise documentation of diagnoses, procedures, and treatments. It enables healthcare providers to communicate critical information about patient conditions and care to other providers, payers, and regulatory bodies. Proper coding enhances communication and minimizes errors and misinterpretations.
• Insurance Reimbursement: Medical coding plays a crucial role in the financial aspects of healthcare. It ensures that healthcare providers are appropriately reimbursed for the services they provide. Accurate coding ensures that claims are correctly processed, minimizing the risk of claim denials or payment delays.
• Data Analysis and Research: Code systems in healthcare facilitate the aggregation and analysis of healthcare data. These coded data sets are invaluable for research, epidemiological studies, and tracking public health trends. Data derived from medical coding can help identify patterns, evaluate treatment outcomes, and guide evidence-based decision-making.
• Compliance with Regulatory Requirements: Accurate coding is essential for compliance with various regulatory frameworks, including government healthcare programs and insurance industry standards. Compliance with coding guidelines helps healthcare providers avoid penalties, audits, and legal consequences.

The Benefits of Professional Medical Coding Services

Healthcare providers can streamline their operations and improve revenue cycles by outsourcing medical coding services to experienced professionals like MBC. Here are some key benefits:

• Expertise and Accuracy: MBC employs certified medical coders who possess in-depth knowledge of code systems and regulatory requirements. These professionals ensure accurate coding, reducing the risk of claim denials and revenue loss due to coding errors.
• Increased Efficiency: By outsourcing medical coding, healthcare providers can focus on core clinical activities while leaving complex coding tasks to experts. This leads to increased operational efficiency, improved patient care, and reduced administrative burdens.
• Cost Savings: Maintaining an in-house coding department can be costly due to hiring, training, and managing staff, as well as investing in technology and software. Outsourcing coding services allows healthcare providers to eliminate these overhead costs and pay only for the coding services they require.
• Compliance and Up-to-Date Knowledge: MBC stays updated with the latest coding guidelines and regulatory changes. Partnering with such a service provider ensures compliance with evolving industry standards, reducing the risk of non-compliance and associated penalties.
• Scalability and Flexibility: As healthcare practices grow, the volume of coding tasks may increase. Outsourcing medical coding services allows providers to scale their coding operations as needed, without the hassle of hiring and training additional staff.

In the ever-changing landscape of healthcare, accurate and efficient medical coding is essential for optimal patient care, revenue cycle management, and compliance with regulatory requirements. By leveraging the expertise of professional medical coding services, healthcare providers can streamline their operations, enhance revenue cycles, and focus on delivering high-quality care to patients.

Medical Billers and Coders (MBC) stands as a reliable partner, offering comprehensive medical coding services to healthcare providers, enabling them to navigate the complexities of code systems with ease and confidence.

For further information about MBC’s medical coding services, please reach out via email at info@medicalbillersandcoders.com or by calling 888-357-3226.

FAQs:

The post The Role of Code Systems in Healthcare Industry appeared first on Medical Billing and RCM Blogs.

Unbundling codes in medical billing refers to the practice of separately billing for individual components of a medical procedure or service, rather than billing for the complete procedure or service as a single entity. This practice can result in higher payments to healthcare providers and higher costs for patients and insurers.

For example, imagine a patient receives a single medical service that includes a group of tests. If the provider bills for each test separately rather than billing for the single service that includes all of the tests, this is considered unbundling. Unbundling can be deliberate or unintentional. Deliberate unbundling is fraudulent and illegal, while unintentional unbundling may occur due to errors in coding or billing.

The Centers for Medicare & Medicaid Services (CMS) has developed specific guidelines to prevent unbundling and ensure accurate coding and billing practices. These guidelines include instructions for when it is appropriate to bill for bundled services and when it is necessary to bill for individual components separately.

Unbundling codes can have significant financial implications for patients and insurers. It is important for healthcare providers to accurately bill for services to ensure fair and appropriate compensation and to avoid potential legal and financial penalties for fraudulent billing practices.

Tips to Avoid Unbundling Codes

Unbundling codes could result in incorrect or excessive reimbursement and is considered fraudulent. Here are some tips to avoid unbundling of codes:

1. Use Comprehensive Codes

To avoid unbundling codes, healthcare providers should use comprehensive codes that accurately reflect the full range of services provided. Let’s discuss an example of how a healthcare provider might use comprehensive codes to avoid unbundling codes.

A patient comes in for a comprehensive physical exam, which includes a routine check-up, a complete blood count (CBC), and a lipid panel. Instead of billing for each service separately, the provider would use a comprehensive code that encompasses all of these services.

For example, they might use the code 99385, which represents a comprehensive preventive medicine evaluation and management of a patient including an age and gender-appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; 18-39 years of age.

By using a comprehensive code like this, the provider can ensure that they are billing for the full range of services provided, without risking potential unbundling issues. It also helps to simplify the billing process and avoid confusion for both the provider and the patient.

2. Understand National Correct Coding Initiative (NCCI) Edits

Make sure you understand the codes and their components before reporting them. Familiarize yourself with the National Correct Coding Initiative (NCCI) edits that provide guidance on which codes can and cannot be billed together.

The National Correct Coding Initiative (NCCI) is a program developed by the Centers for Medicare & Medicaid Services (CMS) to prevent improper payment of Medicare claims. NCCI edits are sets of codes that are used to determine if a procedure or service is appropriate to be billed together.

The NCCI edits contain pairs of codes, referred to as ‘Column One’ and ‘Column Two’ codes. The Column One code is the primary code or procedure being performed, while the Column Two code is a secondary code or procedure that is typically not performed separately from the Column One code.

When a claim is submitted with both a Column One and Column Two code, the NCCI edits will check to see if the codes are allowed to be billed together. If the codes are not allowed to be billed together, the NCCI edits will reject the claim, and the provider will need to submit a corrected claim.

For example, if provider bills for both a lumbar puncture (Column One code) and a spinal tap (Column Two code), the NCCI edits will reject the claim because these two procedures are considered to be the same procedure and cannot be billed separately.

It’s important for healthcare providers and billing staff to be familiar with the NCCI edits to ensure that claims are submitted correctly and avoid potential penalties or fines for improper billing.

3. Regularly Reviewing Claims

Source: freepik.com

Regularly reviewing claims is an important practice to avoid unbundling codes. As disused earlier, unbundling is a practice of separately billing for two or more component parts of a procedure when a single code exists that includes all of the components.

This practice can lead to overbilling and can result in fines and penalties. To avoid unbundling, healthcare providers should review their claims before submitting them to ensure that they are billing appropriately for all components of a procedure.

This review should include checking that all services provided are accurately represented by the codes billed and that the codes do not overlap or duplicate services.

Additionally, healthcare providers should stay up-to-date with coding changes and guidelines to ensure that they are billing correctly. They should also ensure that their staff is trained and knowledgeable in proper coding and billing practices.

Overall, regularly reviewing claims and staying current with coding changes and guidelines is essential to avoid unbundling codes and ensure accurate billing practices.

4. Seek Professional Assistance

Unbundling codes is fraudulent and illegal, as it misrepresents the services that were actually provided, and can result in overbilling and improper payments. If a healthcare provider is found to have engaged in unbundling codes in medical billing, they may face legal action from both government regulators and private insurance companies.

This can include fines, penalties, and exclusion from participation in government healthcare programs such as Medicare and Medicaid. In addition, patients who have been affected by fraudulent billing practices may also have legal recourse to seek damages or compensation for their losses.

To avoid unbundling codes, you need professional assistance from coding experts like Medical Billers and Coders. MBC is a healthcare revenue cycle management company that specializes in medical billing, coding, and practice management services for healthcare providers.

As a medical coding expert, MBC is trained and experienced in accurately coding medical procedures, diagnoses, and treatments for billing purposes.

Our coders have a thorough understanding of medical terminology, anatomy, and physiology, as well as the rules and regulations governing medical billing and coding.

MBC’s team of medical coding experts works closely with healthcare providers to ensure that all medical services are accurately coded and billed.

To know more about our billing and coding services, email us at: info@medicalbillersandcoders.com or call us at: 888-357-3226.

FAQs:

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Key Strategies for Improving Medical Coding Accuracy

1. Hiring Right Resources

Medical coding is a complex process requiring a lot of knowledge and skill. On top of that implementation of revised payer-specific and state-specific coding guidelines is yet another tedious task that requires talent. Implementing revised coding guidelines and evaluating existing coding practices also requires the involvement of a dedicated coder. Therefore, it is essential for practice owners to hire skilled, experienced, and knowledgeable resources who can make necessary shifts then and there. Hiring unskilled or non-specialty-specific coders could result in financial losses as well as compliance issues.

2. Adhering to Frequent Coding Updates

For improvement, medical coding accuracy always looks for payer-specific and state-specific coding guidelines. Most insurance companies consider CMS-released guidelines and coding updates as standard coding guidelines. Still, every insurance company will have unique coding guidelines and insurance companies will expect you to follow them for accurate insurance reimbursements. You can follow CMS and insurance companies for the latest coding updates. You can also frequently login into your provider portal to check any coding updates applicable to your practice.

In case of any coding updates, every insurance company will notify providers well in advance. Insurance companies will also assist you with suggested codes and documentation requirements for the smooth implementation of these coding guidelines. The insurance company also asks for your opinion on proposed coding updates to understand the potential implications of such updates. So, always stay connected with insurance companies for billing and coding updates.

3. Conducting Quality Audit

Coding quality audits can streamline revenue cycle processes, reduce the number of claim denials, and ensure adherence to federal and state healthcare regulations. Performing a coding audit will help to evaluate a sample of charts for individual coders and their recorded codes, thereby, ensuring the quality of clinical documentation. Many practices get assistance from medical billing companies for scheduled coding audits and annual coding compliance audits to get the expertise they lack internally. Coders are empowered to use standardized codes and follow appropriate guidelines to interpret clinical documentation properly. The entire revenue cycle process can be streamlined through quality and compliance audits for coding that could help decrease the number of denials.

4. Conducting Frequent Training

Conducting frequent coding training definitely helps in improving medical coding accuracy. You can conduct coding denials reviews with your coding team periodically, at least once a month. Look at the top 10 coding-related denials and identify the root cause. Often, it may be because of a lack of understanding of the correct codes for a particular procedure or inaccurate clinical documentation maintained in the practice. A brainstorming session can prepare the coders about the correct codes and rectify many coding issues you currently face.

5. Opening Communication Channels

Whether internal or external, a coding audit is a key strategy for improving medical coding accuracy. But just conducting an audit is not enough, practice owners should communicate audit findings and any changes in coding compliance with the coding and billing team as soon as possible. Communicating with the complete billing team will enable coders to alter workflows immediately to improve coding quality. Communication also ensures coders are on the same page with updates to coding compliance, especially when the unexpected happens. Communicating audit results and coding compliance changes with clinicians can be especially beneficial since they are the ones documenting clinical encounters, which will then be translated into claims for reimbursement. Ensuring high-quality medical coding is important for capturing revenue.

6. Avoiding Coder Burnout

Due to the shortage of qualified medical coders, most healthcare organizations have an understaffed coding team. The lack of skilled, knowledgeable, and medical specialty-specific coders has led to unrealistic productivity expectations from the coding team. In most cases, the consistently high workload has led to coder burnout. Hiring enough qualified coders can help you balance the coding team’s workload, set realistic productivity goals, and improve morale, resulting in improved medical coding accuracy.

Outsourcing Coding

Outsourcing your revenue cycle management functions to a medical billing company can be a practical strategy for improving medical coding accuracy. Finding an in-house medical coder could be a challenge for any healthcare practice due to skilled manpower shortage and payroll burden. With such an in-house coder, you constantly have to invest in training and certification charges. Medical billing companies not only provide you the skilled manpower but also they can offer customized coding services as per your practice requirements.

If your practice requires a full-time coder then the billing company can charge you on FTE (Full Time Employee) basis otherwise they will charge you only for work done (either chart-wise or submitted claim-wise). As medical billing and coding are such companies’ core competencies, they can assign skilled, experienced, and medical specialty-specific coder who is well versed with coding guidelines for various payers in your area. Such outsourced coding resources will not only take care of compliance issues but also look for revenue-maximizing opportunities for your practice.

Medical Billers and Coders (MBC) is a leading medical billing company providing complete revenue cycle management services. As a practice owner, if you are facing the challenge of hiring a skilled coder or dedicating time to medical coding and billing operations, outsourcing can be a great option for you. Whether you are looking for a full-time skilled coder or need coding for a few charges, we can provide coding services as per your practice requirements. To know more about our medical billing and coding services, email us at: info@medicalbillersandcoders.com or call us at: 888-357-3226.

FAQs

Q1: What is the role of medical coding in revenue cycle management?

Medical coding plays a crucial role in ensuring clean claims, identifying documentation issues, and improving the overall revenue cycle by maximizing reimbursements without compromising quality.

Q2: Why is hiring skilled medical coders important?

Hiring skilled, experienced coders ensures accurate claim submissions and compliance with state and payer-specific guidelines, reducing financial losses and avoiding coding errors.

Q3: How can I stay updated with the latest coding guidelines?

You can follow CMS updates, check insurance company portals, and stay in touch with payers to receive notifications about any coding updates or changes.

Q4: What are the benefits of conducting medical coding quality audits?

Regular coding audits help reduce claim denials, ensure compliance with healthcare regulations, and improve the overall accuracy of clinical documentation.

Q5: How can coding training help improve accuracy?

Frequent training, such as reviewing coding denials and identifying root causes, can prepare coders to handle specific coding issues and improve accuracy.

Q6: Why is communication important for improving medical coding accuracy?

Open communication about audit results and compliance changes helps ensure coders and clinicians are aligned, leading to more accurate documentation and coding.

Q7: What is coder burnout, and how can it affect coding accuracy?

Coder burnout happens when coders face high workloads due to a shortage of skilled professionals. It can lead to reduced accuracy, but hiring enough coders can alleviate the burden and improve performance.

Q8: Why should practices consider outsourcing medical coding?

Outsourcing provides access to skilled coders without the burden of hiring and training in-house staff. It can improve coding accuracy, ensure compliance, and optimize revenue.

Q9: How can Medical Billers and Coders (MBC) assist with medical coding?

MBC provides customized coding services, offering full-time or part-time coders based on practice needs, ensuring compliance, and maximizing revenue opportunities.

The post Key Strategies for Improving Medical Coding Accuracy appeared first on Medical Billing and RCM Blogs.

Selecting accurate diagnosis codes using ICD-10-CM is challenging due to the availability of more than 68,000 codes. In this blog, we shared general coding guidelines for ICD-10-CM, which will help you select accurate diagnosis codes. Before we proceed with coding guidelines, you’ll need access to two lists in ICD-10 CM: the Alphabetical Index of diagnostic terms and the Tabular List of ICD-10 codes.

The Alphabetical Index of diagnostic terms lists thousands of ‘main terms’ alphabetically. Under each of those main terms, there is often a sub-list of more detailed terms; for instance, ‘Cataract’ has a sub-list of 84 terms. The Tabular List of ICD-10 codes is organized alphanumerically from A00.0 to Z99.89. It is divided into chapters based on body parts or conditions.

General Coding Guidelines for ICD-10-CM

Locating a code in the ICD-10-CM 

To select a code in the classification corresponding to a diagnosis or reason for a visit documented in a medical record, locate the term in the Alphabetic Index and then verify the code in the Tabular List.

Read and be guided by instructional notations in the Alphabetic Index and the Tabular List. It is essential to use both the Alphabetic Index and Tabular List when locating and assigning a code.

The Alphabetic Index does not always provide the complete code. The entire code, including laterality and any applicable 7th character, can only be selected in the Tabular List.

A dash (-) at the end of an Alphabetic Index entry indicates that additional characters are required. Even if a dash is not included in the Alphabetic Index entry, referring to the Tabular List is necessary to verify that no 7th character is required.

Level of Detail in Coding 

Diagnosis codes are to be used and reported at the highest number of characters available and to the highest level of specificity documented in the medical record. ICD-10-CM diagnosis codes are composed of 3, 4, 5, 6, or 7 characters.

Codes with three characters are included in ICD-10-CM as the heading of a category of codes that may be further subdivided by using fourth, fifth, or sixth characters, which provide greater detail.

A three-character code will be used only if not further subdivided. If applicable, a code is invalid if it has not been coded to the total number of characters required for that code, including the 7th character.

Multiple Coding for a Single Condition 

In addition to the etiology/manifestation convention that requires two codes to describe a single condition that affects multiple body systems entirely, other single conditions also need more than one code. ‘Use additional code’ notes are found in the Tabular List for codes not part of an etiology/manifestation pair where a secondary code is helpful in fully describing a condition.

The sequencing rule is the same as the etiology/manifestation pair. ‘ Use additional code’ indicates that a secondary code should be added if known. 

Combination Code 

A combination code is a single code used to classify two diagnoses: a diagnosis with an associated secondary process (manifestation) or an associated complication. Combination codes are identified by referring to sub-term entries in the alphabetic index and reading the inclusion and exclusion notes on the tabular list.

Assign only the combination code when that code fully identifies the diagnostic conditions involved or when the Alphabetic Index directs. Multiple coding should not be used when the classification provides a combination code that identifies all the elements documented in the diagnosis.

When the combination code lacks specificity in describing the manifestation or complication, an additional code should be used as a secondary code.

Sequela (Late Effects) 

A sequela is a residual effect (condition produced) after the acute phase of an illness or injury has terminated. There is no time limit on when a sequela code can be used. The residual may be apparent early, such as in cerebral infarction, or it may occur months or years later due to a previous injury.

Examples of sequela include scar formation resulting from a burn, deviated septum due to a nasal fracture, and infertility due to tubal occlusion from old tuberculosis. Coding of sequela generally requires two codes sequenced in the following order: the condition or nature of the sequela is sequenced first. The sequela code is sequenced second.

Use of Sign/Symptom/Unspecified Codes 

Sign/symptom and ‘unspecified’ codes have acceptable, even necessary, uses. While specific diagnosis codes should be reported when supported by the available medical record documentation and clinical knowledge of the patient’s health condition, there are instances when signs/symptoms or unspecified codes are the best choices for accurately reflecting the healthcare encounter. Each healthcare encounter should be coded to the level of certainty known for that encounter. 

Impending or Threatened Condition 

Code any condition described at the time of discharge as ‘impending’ or ‘threatened’ as follows: 

• If it did occur, code it as the confirmed diagnosis. 
• If it did not occur, reference the Alphabetic Index to determine if the condition has a subentry term for ‘impending’ or ‘threatened’ and also reference primary term entries for “Impending” and ‘Threatened.’
• If the sub-terms are listed, assign the given code. 
• If the sub-terms are not listed, code the existing underlying condition(s), not the condition described as impending or threatened.

Remaining Coding Guidelines for ICD-10-CM

Here are some additional important guidelines to keep in mind when coding with ICD-10-CM:

• The appropriate codes from A00.0 through T88.9, Z00-Z99.8, and U00-U85 must be used to identify diagnoses, symptoms, conditions, problems, complaints, or other reason(s) for the encounter/visit.
• Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when the provider has not established a related definitive diagnosis.
• Signs and symptoms associated routinely with a disease process should not be assigned as additional codes unless otherwise instructed by the classification.
• Additional signs and symptoms that may not be associated routinely with a disease process should be coded when present.
• If the same condition is described as acute (sub-acute) and chronic, and separate subentries exist in the Alphabetic Index at the same indentation level, code both and sequence the acute (sub-acute) code first.
• Each unique ICD-10-CM diagnosis code may be reported only once for an encounter. This applies to bilateral conditions when no distinct codes identify the same ICD-10-CM diagnosis code classifies laterality or two different situations.
• Some ICD-10-CM codes indicate laterality, specifying whether the condition occurs on the left, right, or is bilateral. If no bilateral code is provided and the condition is bilateral, assign separate codes for both the left and right sides. If the side is not identified in the medical record, assign the code for the unspecified side.
• If the provider documents a ‘borderline’ diagnosis at the time of discharge, the diagnosis is coded as confirmed unless the classification provides a specific entry (e.g., borderline diabetes). If a borderline condition has a particular index entry in ICD-10-CM, it should be coded as such. Since borderline conditions are not uncertain diagnoses, no distinction is made between the care setting (inpatient versus outpatient). 

Medical Billers and Coders (MBC) is a leading medical billing company that provides complete billing and coding services. For provider education purposes, we shared general coding guidelines for ICD-10-CM. The following link provides a detailed explanation.

In case any assistance is needed for medical billing and coding, contact us at 888-357-3226 / info@medicalbillersandcoders.com

FAQs

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A coding audit is a review of a medical office’s coding practices conducted by reviewing patient medical records. Medical record audits target and evaluates procedural and diagnosis code selection as determined by physician documentation for completeness and accuracy. Medical audits cover: assessing the proper use of CPT codes; determining the correct places of service; finding out missing and/or incorrect use of modifiers; detecting incorrect diagnoses; documentation accuracy; identifying any bundling or cluster issues.  

Accurate coding by Physicians is critical to getting paid for the services provided and for avoiding external audits by Medicare and other private Payers. The easiest and probably best way is to audit a select sample of charts. MedicalBillersandCoders (MBC) provides coding compliance audits to physicians which enables them to make corrections before their coding is questioned by the payers. Our coding audit services are designed to help you maintain compliance with different industry standards. Our coding audit services also enable the providers to fully code the encounters which may otherwise have been down-coded. 

Benefits of Medical Coding Compliance Audit

• Maintain compliance: In COVID-19 pandemic coding guidelines are being updated continuously, a new set of reimbursement policies are introduced constantly, so staying compliant is challenging. Coding audits identify new laws, regulations, payer rules, and other issues that are applicable to your medical specialties. The audit will help you apply new codes and changes correctly from the beginning. The Office of Inspector General (OIG) also requires at least an annual audit to maintain compliance. Conducting audits on a quarterly or a monthly basis helps avoid lapses in compliance early.
• Reduce claim rejections and denials: Periodic coding audits result in more accurate medical coding resulting in fewer rejections and denials. Major reasons for claim denial are insufficient documentation, wrong procedure, and diagnosis codes, which get covered in coding audits. Coding audits at regular intervals of time provide a great way to identify and correct issues so that more claims can be paid on time and in full. Coding at the right level means that are you are paid correctly and not settling for less than you are owed. Your practice deserves to receive the correct reimbursement from private as well as government payers.
• Educate your staff: Perhaps the most important benefit of regular coding audits is having the opportunity to educate your staff. Medical coding accuracy evaluations should be included in a continuous quality improvement program. Frequent audits provide the feedback you need to identify education opportunities and devise a plan to implement them.
• Maximize reimbursement: Fewer mistakes by undertrained or overworked coding staff result in more claims getting paid. Rejections and denials slow you down and cost you money. Improving the quality of your coding through regular coding audits keeps your office running efficiently. These benefits ensure that you use your staff’s time efficiently, and cash flow is maximized. Regular coding audits reduce overpayments and underpayments, lower the rate of rejections and denials, keep your practice compliant, encourage your staff to focus on quality coding, and ultimately maximize your profit.
• Prevent payer audit/investigations: If coding problems persist and payers find irregularities then your practice can be flagged for investigation. The investigation looks for potential fraud by the practice. These investigations are stressful and costly. If fines are levied, serious financial consequences may ensue. Regular coding audits educate and improve your practice and ensure that your practice will not be flagged for fraud, waste, or abuse.

To Summarize

The purpose medical coding audit is to improve coding compliance for your practice. Audit reports would be discussed to review internal coding methodologies and methods for calculating error rates, numbers and rates of issues, trends, and more. This report will provide an excellent learning opportunity for staff. The audit report identifies the root cause of some of your coding discrepancies. Regardless of the areas of improvement identified in a particular audit, implementing the changes make your practice run more efficiently.

MedicalBillersandCoders (MBC) is one of the leading revenue cycle service providers. Along with overall revenue cycle services, we also help practices in coding compliance audits. We utilize current AMA and industry coding guidelines, Correct Coding Initiative (CCI)edits, CMS (Medicare) specialty-wise coding conventions and practices. Our medical coding audit services also include a case-by-case analysis of our findings. Our medical coding accuracy audits are designed to be part of a continuous quality improvement program. It gives the providers and surgical coders the feedback they need to more accurately code the patient-care services. To know more about our billing and coding services, contact us at info@medicalbillersandcoders.com/ 888-357-3226.

FAQs

1. What is a medical coding compliance audit?

A medical coding compliance audit is a review of a practice’s coding processes, which involves evaluating patient medical records, procedural and diagnosis code selection, and ensuring that coding is accurate, complete, and compliant with industry standards. It helps identify errors such as incorrect CPT codes, missing modifiers, incorrect diagnoses, and bundling issues.

2. Why is a coding audit important for my practice?

Coding audits are crucial because they help ensure that your practice stays compliant with changing medical billing guidelines, minimizes the risk of claim denials, and prevents costly payer investigations. They identify areas of improvement in coding practices and reduce the chance of underpayments or overpayments, ensuring that you receive accurate reimbursement.

3. How often should coding audits be conducted?

It is recommended to conduct coding audits regularly, either monthly or quarterly. The frequency depends on your practice’s size, the volume of claims, and the complexity of services provided. Regular audits help keep your practice compliant, improve coding accuracy, and avoid discrepancies that could result in claim denials or payer investigations.

4. What are the benefits of regular coding audits?

Regular coding audits help ensure compliance with current regulations, reduce claim rejections and denials, educate your staff on coding best practices, and maximize reimbursement. By identifying coding errors early, audits improve the accuracy of claims, enhance cash flow, and reduce the risk of costly investigations.

5. How does a coding audit reduce compliance risk?

By identifying and correcting errors in coding practices before they become significant issues, regular coding audits reduce compliance risks. They help prevent practices from being flagged for potential fraud, waste, or abuse. This proactive approach ensures that your practice avoids costly investigations and maintains accurate, compliant billing practices.

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One of the main challenges of medical coding originates from the lack of medical coding specialists. The second challenge is insufficient communication between providers and coders. Due to the COVID-19 pandemic, many coders have to work remotely hence widening this communication gap between provider and coder.

For improving medical coding quality, we discussed few possible solutions i.e., frequently performing quality audits, using technology, and opening communication channels.  

Performing Quality Audits

Frequently performing coding quality audits is an essential element for improving medical coding quality. As per a study report conducted by Change Healthcare, over $262 billion in claims are initially denied every year largely due to insufficient clinical information. The same study also found that $28 billion in the denied funds were directly linked to a lack of clinical documentation.

Monthly internal coding audits will prevent such ‘soft’ denials that require additional information for reimbursement. Performing quality audits will ensure that all coders are following payer-specific coding guidelines.

Frequent coding audits can identify areas that are leading to revenue leakage whether because of bad habits, workflow issues, or even lack of training. Coding audits will highlight any differences between your practice’s billed data and the national average. This difference may be caused due to potentially fraudulent or non-compliant coding and billing practices.

Coding audits will also give your practice an outsider’s perspective to your medical coding quality. For coding audits to be effective, they should be carried out regularly, the data should be stored in the proper format for comparing. 

Use Technology

Computer-assisted coding solutions can help you to improve the quality and accuracy of medical coding. Computer-assisted coding (CAC) solutions are software products that can analyze healthcare documents to identify the appropriate medical codes for clinical documentation.

With computer-assisted coding software, there is no need to dig through coding books. This technology will automatically alert on CCI and LCD edits, and your coder will be presented with auto-suggested codes, which will in turn increase accuracy.

Opening Communication Channels

Constant communication between provider and coding team is important as it will ensure that all procedures are documented properly, it’s coded properly, and no procedure is missed considering it as a non-billable procedure. Providers should communicate audit findings and any changes in coding compliance with coders as soon as possible.

It will help coders to modify workflows immediately to improve coding quality. Communication also ensures coders are on the same page with updates to coding compliance, especially when so many coding updates are released.

Every year new codes are added, few codes are deleted, and some codes are revised. In years 2020 and 2021 we witnessed many revisions to coding that included changed telehealth guidelines, the addition of many new codes related to the COVID-19 vaccine and administration, and changed coding guidelines for all payers. When such revisions happen, coders and providers should proactively work together to standardize coding processes. 

Have a Coding Team

For small practices, most providers prefer to handle medical coding all by themselves. But medical coding is not just choosing the correct procedural codes and billing them.

Medical coding involves payer-specific documentation, accurately choosing procedural codes, choosing accurate modifiers as per clinical scenarios, appealing denials with the required information, and coding audits to check compliance to payer coding guidelines.

As providers are busy in inpatient care, they don’t have sufficient time to keep track of coding updates and payer-specific guidelines. So, it’s better to let coding professionals handle medical coding for you. 

As providers move to value-based reimbursement, guaranteeing medical coding quality will be key not only for getting paid for services but capturing the quality of care delivered.

If you need any assistance in improving medical coding quality for your practice, contact us at info@medicalbillersandcoders.com / 888-357-3226

FAQs

1. Why is medical coding important for revenue cycle management?

Accurate coding ensures claims are processed quickly, leading to faster reimbursements and reduced revenue leakage.

2. What are the common challenges in medical coding?

Challenges include a lack of medical coding specialists and poor communication between providers and coders, especially with remote work.

3. How can coding audits help improve coding quality?

Regular coding audits identify errors, bad habits, and training gaps, ensuring compliance and preventing denials.

4. How does technology improve medical coding?

Computer-assisted coding software helps improve accuracy by automatically suggesting codes and alerting coders to compliance issues.

5. Why is communication between providers and coders important?

Continuous communication ensures proper documentation, coding, and compliance, especially with frequent coding updates and changes.

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Post-op care falls into this category of care when the condition that precipitated the surgery no longer exists, but the patient still requires therapy care to return to a healthy level of function. Diagnosis coding guidelines for aftercare are mentioned along with suitable clinical examples in this article. 

Aftercare Diagnosis Coding Guidelines

ICD-10 makes two important points about the use of aftercare codes: 

1. The aftercare Z code should not be used if treatment is directed at a current, acute disease.
   • The aftercare Z code should not be used if treatment is directed at a current, acute disease. The diagnosis code is to be used in these cases. Exceptions to this rule are codes Z51.0, Encounter for antineoplastic radiation therapy, and codes from subcategory Z51.1, Encounter for antineoplastic chemotherapy and immunotherapy. These codes are to be first listed, followed by the diagnosis code when a patient’s encounter is solely to receive radiation therapy, chemotherapy, or immunotherapy for the treatment of a neoplasm. If the reason for the encounter is more than one type of antineoplastic therapy, code Z51.0 and a code from subcategory Z51.1 may be assigned together, in which case one of these codes would be reported as a secondary diagnosis.
2. The aftercare Z codes should also not be used for aftercare for injuries. 
   • Aftercare for injuries during the healing and recovery phase should be coded with the injury code and the appropriate 7th character for subsequent encounters rather than a Z code. An example would be aftercare for an unspecified fracture of the lower end of the right humerus. Because the patient is returning for treatment during the healing and recovery phase, the diagnosis code for the injury S42.401 would have the 7th character of ‘D’ to indicate the encounter is a subsequent encounter for aftercare with routine healing. Additional subsequent encounter 7th characters are available to describe delayed healing, non-union, or malunion. This diagnosis code with the correct 7th character would be first listed. 
3. The aftercare codes are generally first listed to explain the specific reason for the encounter. An aftercare code may be used as an additional code when some type of aftercare is provided in addition to the reason for admission and no diagnosis code is applicable. An example of this would be the closure of a colostomy during an encounter for treatment of another condition.
4. Aftercare codes should be used in conjunction with other aftercare codes or diagnosis codes to provide better detail on the specifics of an aftercare encounter visit unless otherwise directed by the classification. The sequencing of multiple aftercare codes depends on the circumstances of the encounter.
5. Certain aftercare Z code categories need a secondary diagnosis code to describe the resolving condition or sequelae. For others, the condition is included in the code title. Additional Z code aftercare category terms include fitting and adjustment, and attention to artificial openings.
6. Status Z codes may be used with aftercare Z codes to indicate the nature of the aftercare. For example, code Z95.1, Presence of aortocoronary bypass graft, may be used with code Z48.812, Encounter for surgical aftercare following surgery on the circulatory system, to indicate the surgery for which the aftercare is being performed. 
7. A status code should not be used when the aftercare code indicates the type of status, such as using Z43.0, Encounter for attention to tracheostomy, with Z93.0, Tracheostomy status.

Aftercare vs. Follow-up Codes

Follow-up codes are used to explain continuing surveillance following the completed treatment of a disease, condition, or injury. They imply that the condition has been fully treated and no longer exists. They should not be confused with aftercare codes that explain current treatment for a healing condition or its sequelae represented with the 7th character for subsequent encounters.

Follow-up codes may be used in conjunction with history codes to provide the full picture of the healed condition and its treatment. The follow-up code is sequenced first, followed by the history code. A follow-up code may be used to explain repeated visits. When a condition has recurred on the follow-up visit, assign the diagnosis code in place of the follow-up code.

An example would be a follow-up visit for a patient after completing a regime of IV antibiotics for recurrent pneumonia; now resolved. Z09 for follow-up not related to malignant neoplasm is sequenced first followed by the history of (recurrent) pneumonia, Z87.01, to describe the condition now resolved.

We hope these diagnosis coding guidelines for aftercare will help you to accurately choose diagnosis codes. In case of any assistance required in diagnosis and/or procedural coding and overall medical billing services, contact us at info@medicalbillersandcoders.com/ 888-357-3226 

FAQs:

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