It Only Takes One Code

May 02, 2019

How many times have you heard “it only takes one code to get the claim paid”?


With the emphasis on the severity of illness and the move toward value-based reimbursement in today’s healthcare climate, it is more important than ever for coders to report all applicable diagnoses.

There are three important pieces: what the provider documents, how to the coder interprets that documentation and codes it, and then how it is extrapolated.

  • Provider: The provider documents the patient’s record/notes to give the full picture. But is the provider documenting all the chronic conditions being considered during the encounter? Are all diagnoses being documented to the highest level of specificity? Value-based reimbursement requires the most comprehensive documentation. It encourages providers to document, to the highest level of specificity, all conditions being considered while treating the patient. Including any chronic conditions still actively being treated, some of which may fall into Hierarchal Condition Categories (HCCs).
  • Coder: The diagnoses and procedures documented by the provider are assigned ICD-10/CPT codes to be submitted on the 1500 form. Coders should query the providers if documentation is conflicting or missing to ensure all conditions are reported appropriately. With the increasing push towards value-based reimbursement, it is especially beneficial for coders to have a solid understanding of HCCs.
  • Extrapolation: The Centers for Medicare & Medicaid Services (CMS) extrapolates the billed data to determine practice, quality, and cost trends. If any documentation is missing, it may not reflect an accurate accounting.

It’s clear that the key in optimizing reimbursement is complete and thorough documentation. A fresh set of eyes may pick up on something that has previously gone unnoticed – like lacking documentation. In addition to providing constructive coder feedback, scheduling an external audit can also help uncover potential template or system irregularities, which are often easy to correct.

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