Medical Coding 101 – Insights, Challenges and Standard Practices

Nokomis Health | Medical Coding 101


What are CPT Codes?
As you may know, every procedure code on a claim is tied into a dollar amount. So if a coder miscodes something, the provider could be paid for a code that isn’t supported by the documentation or the clinic may be losing reimbursement that is rightly due to them. Miscoding is typically a result of coders lacking education and not knowing how to code properly or they may be trying to game the system. That’s why insurance companies need a claim review partner. We can look for trends that we see in the claims and set an edit to manually review those claims or automatically deny them. Just because there is a CPT code doesn’t mean that you can use that code for reimbursement or use it for reimbursement in combination with other codes.

What education do you need to have to become a coder?

The minimum qualification that most employers want is certification from either AHIMA or AAPC. These certifications can be obtained with a variety of educational backgrounds. You can attend a formal Associates or Bachelors degree program. You can also work towards certification with a minimum of two years of working experience. I highly recommend that whatever route is taken, coders need to have a strong background in medical terminology, anatomy, and pathophysiology. You cannot be a successful coder without understanding what you are trying to code. In my opinion, you need to work at a doctor’s office or a hospital and be involved in applying codes on a daily basis for several years to have the proper understanding and expertise.

There are people out there handling the coding that have not gone through any schooling for this type of work. It’s not uncommon for hospital bills and doctor’s bills to be coded by people who have very little education in this area.

Some facilities do not have coders that logically think about why a certain procedure is being documented on a claim. The procedures need to match up and make sense. Without the proper background or education, a coder couldn’t tell the difference. At Nokomis, we look for those mismatches within the claims. If we notice procedures being done that just don’t make sense with the other procedures on that claim we dig into them to see what’s going on and make sure proper payment is being made.

What are some aspects of your job that you think young coders may be unaware of?

I feel that many new coders believe that ANYONE can become a coder and work from home. That’s the message they might hear in an advertisement on TV. In reality, a coder needs to have exceptional analytical skills, a strong foundation in anatomy and pathophysiology, and the ability to translate the documentation to the codes within the parameters of the established coding guidelines. It’s really not as easy as many people think.

Could you talk a little about the ethics of coding?

Both AHIMA and the AAPC have ethical statements. Standards of Ethical Coding and Code of Ethics, respectively, which can be viewed here:

It is my opinion that regardless of whether you are working for a healthcare provider, consulting firm, or a payor, you should always follow all coding guidelines. It is not appropriate for a payor to deny payment on a code without a valid reason. They should be able to provide you with a valid reference to support the denial. A coder, regardless of their employer, should be focusing on correct coding based on the coding guidelines and the provider’s documentation.

Some insurance companies will just outright deny claim lines to see if the provider will appeal it. To us, that’s not the right thing to do either. There are a lot of inappropriate practices in the industry, providers that are gaming the system resulting in inappropriate reimbursement to them, but there are also the honest ones working their tails off just to make ends meet. You don’t know which ones are which until you get in there and start digging into these claims.

Why do companies try to cheat the system or upcode?

Either it is because they want to make money or they just have a lack of understanding. The coding system is very complex. So not understanding “correct coding” is a big issue. Providers may have an untrained staff member doing the coding. In small, single provider practices, this may often be the provider’s spouse. You can just imagine how that complicates “correct coding” behaviors.

Why do you think claim review is not a popular standard practice?

Because of the volume of claims that come through. Some organizations may think that they are conducting proper claim review, but they are not doing it to the depth that they should be.

For a payor, claim review is a complex process. The sheer volume of claims received each day and the need to make payment to the provider within the prompt payment requirements is a lot of work. Conducting proper claim review is about not only looking at all the codes on a single claim, but also factoring in multiple claims from the same day and prior services. Those are just code edit issues. The payor is also faced with properly paying in regards to benefits, deductibles and co-insurance, prior authorizations, and medical policy.

Why Nokomis?

The real value behind Nokomis is our depth of knowledge. We can read the story behind the codes. Our founder Rich has talked about this many times. It’s not just about deducing what NCCI says you can and cannot code together. It’s about looking at the bigger picture of the claim. We look at all the pieces and all the patterns in the history of billing. If the provider has only made one mistake, we deny only that one claim. On the flip side, if the provider is billing incorrectly all the time we will flag them and review all of their claims. It’s about looking deeper than just the codes.

Good coders are under appreciated. It’s really hard to find a coder that can code every section in the CPT book. That’s a part of the void we are trying to fill for our clients, because even if you have one coder they probably can’t code every single section of the CPT. Coders specialize in certain areas and acquire different certifications. At Nokomis, we have a built a strong team of coders to cover the entire coding landscape.