Outsourcing Medical Coding

When is it best to outsource medical coding?

Whether or not you work in a doctor's office or billing agency, sometimes it's necessary to outsource your medical coding.

Medical coding can be very complicated, requiring the specialized knowledge of a certified coder to make sure your claims are coded correctly. This means hiring an outside agency or individual coder to look through the medical record documentation from the date of service and have them assign the correct codes from the visit or procedure.

The following are situations in which it may be necessary to hire an outside coder, or outsource your medical coding, in order to make sure your claims are coded correctly.

Untrained coders in your office

If you work in an office with untrained coders, then it may be necessary to outsource your medical coding needs.

Most of the time in doctor's offices, the doctors themselves code the office visits. Although doctors are not technically trained in coding, most of them have a rudimentary knowledge of it, and are OK coders.

This means that they can usually code for office visits or procedures that they commonly perform and are used to, but when faced with a situation they haven't encountered before, they will probably have trouble assigning the correct codes. This goes for procedure codes as well as diagnosis codes, as they can oftentimes both be confusing.

If the doctor in the office does not have a trained or certified coder to rely on in these situations, then they will just have to guess at the correct code. And when it comes to coding, guessing will not do, as it can result in improper payment, and possibly medical coding fraud or abuse.

Understaffed office

If you are working in an office that is understaffed, and untrained in coding, it may be especially important to outsource your medical coding. The last thing you want in an understaffed office is threats of audits or fines due to improper coding.

This will only use up more time and resources than you already have, and can result in the closing of your office.

Doctors also outsource medical billing

If you work in a doctor's office that also outsources their medical billing, it may be necessary to outsource the coding as well. Some medical billing companies hire trained and certified coders to help in the coding of the claims that they bill for, in order to make sure that all claims are handled correctly.

If your doctor is untrained and uncertain about their codes and they hire an outside billing agency, then make sure that this agency is also able to code the claims appropriately. They will be the ones to double-check the coding work of the doctor.

Having a certified coder look over a doctor's claims is also helpful because they may be able to identify additional codes to bill for, and increase reimbursement for your office.

Expert in Billing but not Coding

If you work in a medical billing office, then you are trained or certified in medical billing. This does not exclude any training in coding, but does not mean that if you work in a medical billing office, you will have certified coders in your office at your disposal.

Medical billing and coding differ greatly. Medical billing includes knowing how insurance companies work, how they process claims, and how to bill and appeal claims, manage accounts receivable and bill patients and handle patient or insurance collections.

Medical coding, on the other hand, includes knowing the specifics of certain coding situations, including knowing coding guidelines, the proper usage of modifiers, bundled services, CCI edit knowledge, as well as the ability to select the appropriate code, which in itself is difficult enough sometimes.

So it follows, then, that if you work in a medical billing office that doesn't have any trained coders, then you may have to outsource your coding to make sure that all of the claims that you are billing are coded correctly.

Especially difficult coding situations

As mentioned before, some coding is very difficult. This means that it may be appropriate to outsource coding for procedures or diagnoses that are complex and difficult to code.

Some of the following types of procedure coding are especially difficult:

Some of the following are difficult diagnosis code categories:

  • Maternal conditions
  • Diabetes
  • Hypertension
  • Poisonings and toxic effects
  • External causes of illness and injury
  • Burns
  • Neoplasms

Any types of coding can be difficult or be complicated but the ones listed above are somewhat difficult even in their simplest forms. They become even more difficult when there are multiple diagnoses or more than one procedure is performed at the same office or hospital visit.

In any of these situations it might be a good idea to outsource your coding to a coder who is certified in a particular area of coding expertise. For example, it may be necessary to outsource your cardiovascular or interventional radiology coding to a CIRCC (Certified Interventional Radiology Cardiovascular Coder).

Previously audited or fined

And finally, once of the most important things about making sure you assign the correct codes, besides proper reimbursement, is avoiding any allegations of abuse, fraud, and fines.

If your office codes for its claims inappropriately, whether it is on purpose or not, you are still responsible for correcting the errors. If an insurance agency finds out that you have been billing incorrectly and have not corrected the errors, then they may audit your files to check them all for incorrect coding.

Going through an audit is bad enough, but if the auditing agency finds that you have billed many claims in error without any attempt to correct the claims, then they may accuse your office of fraudulent or abusive billing.

Depending on the extent of the fraud or abuse, your office may have to pay fines or go to court, and in the most severe cases, your doctor or office manager can go to jail, and your office will be shut down.

All of this means that if your office has previously been audited and your coding has been found inappropriate, it may be necessary to outsource your coding to make sure that a certified and trained coder codes all of your claims correctly. This will help avoid future audits, and in the case of an audit, will reduce the likelihood that any of your claims have been billed incorrectly.

If you are in any of the above situations you may find it necessary to outsource your medical coding needs. Making sure your claims are coded correctly in turn makes sure that your office is paid the maximum amount, as well as helps to avoid any audits and allegations of fraud or abuse.

If you found this page useful, please click "Like"! Thanks.