How To Increase Compliance and Reduce Coding Challenges in 2025
Staying up to date on the ever-changing regulations and requirements of coding and documentation can be challenging.
Here are some essential ways that everyone from clinical providers to coders, billing and revenue staff, compliance, and even IT personnel can use to help ensure that the organization as a whole operates in an effective, profitable and legally compliant manner.
Update EHR systems
Each year the organization’s EHR system must be updated with the latest coding software to ensure that the most current codes are available for use on and after their effective date and any deleted codes have been restricted for use to only past dates. Typically, this involves a partnership between the IT department and the coding and/or compliance department to integrate the current updates to the EHR system.
ICD-10 coding updates must be available for use by October 1st each year and CPT code updates must be available for use by January 1st of each calendar year.
Outdated software systems can result in claims processing issues and improper coding which could impact reimbursement or trigger audits.
Update ICD-10 Codes
ICD-10 updates are published and implemented each year on April 1st and October 1st. October 1st is the annual update with new codes added, and existing codes revised or deleted. Guidelines are also updated and revised annually for October 1st.
April 1st is a mid-year update and generally includes far less changes, though sometimes the updates include corrections or revisions. It is essential to review the changes in advance of the annual update and provide education and guidance to all personnel involved in the coding process prior to the October 1st implementation of the codes. If there are documentation requirements associated with new ICD-10 codes make certain that clinical providers are aware of what is required to support accurate coding.
Update CPT codes
The CPT Editorial Panel is authorized by the AMA and responsible for maintaining the CPT code set. The AMA prepares for the annual update of CPT codes for release in the fall of each year preceding the effective date and implementation of the codes on January 1st. CPT codes are added, revised or deleted based on review of the CPT Editorial Panel. Guidelines for CPT code sets may be updated as well in accordance with changes to the codes in each category and use of emerging technologies.
Category I vaccine products and Category III codes are typically “early released” on either January 1st or July 1st for implementation effective 6 months subsequent to their release. Codes that are “early released” on January 1st are effective for use on July 1st and codes “early released” on July 1st are effective for use on January 1st; this allows time for their review and implementation.
It is crucial that all changes to CPT codes and guidelines be reviewed well in advance of their January 1st implementation (or in the case of early release codes prior to their subsequent effective date). Education and guidance should be provided to all personnel involved in the coding process to ensure accurate coding is utilized regarding all changes. Clinical providers should be updated on documentation requirements associated with code changes to ensure that details support the code requirements.
Correct use of modifiers
Misuse of modifiers can result in overpayments, and lack of use can result in rejections, underpayments or delay in reimbursement. Either situation can put an organization at risk. Education should be provided to all coding, billing and revenue staff to ensure that modifiers are correctly reported and are supported by the documentation to mitigate risks associated with incorrect reporting. Many payors, as well as the OIG, regularly monitor and audit for modifier usage.
Follow bundling rules
Everyone involved in the coding process should be provided with education on the risk of improper unbundling to individuals and organizations. Documentation must be supported by separate services to ensure that incorrect unbundling does not occur, and edits should be thoroughly checked prior to claim submission as a verification method. Incidental procedures should not be separately reported. Neither should inclusive procedures. Coders, clinical providers and any others involved in the coding process should be educated on what the coding guidelines are related to inclusive, bundled and separate services.
Understand the differences between outpatient or professional and inpatient or facility coding
There is a difference between outpatient/professional coding and inpatient/facility coding. Typically, coding staff does either professional or facility coding. However, single-path coding has increased in frequency recently, whereby the coding staff codes for both the professional services and the facility services.
When the professional and facility coding are performed by different staff members they may not always align. If claim reporting of hospital services for the physician and facility have discrepancies, then claims may be denied and/or reimbursement may be impacted.
Members of the revenue integrity or compliance department should oversee that there is communication and alliance with these services to ensure not only correct coding is reported but there is minimal impact to accurate and timely reimbursement.
Audit for correct coding and documentation improvement
Whether an internal process is implemented for auditing of documentation and coding or an external audit service is contracted, it is essential that frequent oversight be performed. Auditing should not be considered a punitive measure but rather one in which improvements can be made. If there is documentation which is lacking in detail then accurate coding may not be achieved. Likewise, if there are coding deficiencies due to a lack of understanding of coding guidelines, this could result in a negative impact on revenue or a risk due to improper coding.
Education for coding improvement or CDI improvement
Audit results should be followed by education to provide feedback to both clinical providers as well as coders, billers, and revenue personnel so that improvements can be made. Provide support for audit findings with regulatory guidance for a better understanding of the requirements for detailed documentation and accurate coding.
Stay up to date on regulatory changes which can occur outside of the regular coding updates
As stated earlier, coding and documentation requirements are constantly changing. It is crucial to stay updated by following regulatory entities such as the AMA, CMS, and HHS. Publications and releases should be regularly reviewed for the relevance of updates and/or changes to the individual practice, specialty, or organization.
Stay updated on the OIG workplan
To mitigate risk to individuals and organizations, it is imperative that the OIG work plan be reviewed at least monthly for the areas being audited or areas deemed to be on the watchlist. These areas are the most crucial for proactive audits, which can uncover inadequacies and produce improvement if necessary.
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