8 Steps To Ensure Efficient Coding For Healthcare Company

8 Steps To Ensure Efficient Coding For Healthcare Company

Hospital physicians use to focus on the patient’s healthcare earlier but now they have to perform non medical tasks too. It is important for hospitals to build good will in the patients and perform the correct patient’s diagnosis together with the skills to ensure proper reimbursement process.


You need to remember few things when coding for reimbursement. These things will make sure that the your revenue management is on the right track:

1. Documenting history during Initial visit

You need to document all the visits thoroughly. This involves patient’s history, physical assessment and the process of making medical decision. Your document should cover the areas of:

  • Patient’s chief complaint
  • Diagnosis of patient
  • Family history

Each of these history is important and shouldn’t be left out. One of the most overlooked history is the family history. The service which is rendered should be down coded regardless of comprehensiveness of document. In order to make a smooth discharge process, you need to know about the social history of the patient. Sometimes it is the social circumstances which contributes to the hospitalization. At times, some discharges needs assistance of social worker.

2. Organ System Documentation and Medicare State Rules

This should be on the priority that the hospitalist should always get familiar with the rules of their practice. Rules and procedure vary between states. Reviews are created by the auditors depending on how many organ systems are getting documented. In case you are not following a systematic review system, it can financially affect the hospital.

According to some State rules, documentation done by healthcare of each organ is individually reviewed. In other procedure, health care has to give a documentation of review with relevant negative and positive findings.

3. Conveying Condition of the Patients

Your hospital staff needs to be careful about the documentation of patient’s condition. Hospitalists need to mention whether the condition is acute or chronic, systolic or diastolic. Don’t reduce your reimbursement because of failure in identifying specify nature of the condition.

4.  Acute Diagnosis for Efficient Coding

Make sure there are no loopholes in your documentations. Your coders can assign the right codes, if you have documented the actual diagnosis properly. This will ensure the coders from your end and without any further inquiry can go ahead with the task of assigning codes.

5. Physician’s Role in Treatment

If there are multiple physicians involved in the treatment of a patient. Apart from specialists involvement, role of each clinical member involved should be made sufficiently clear. Towards the end the codes should be able to support each and every service that is rendered. You need to keep this in mind that you have to only code for the specific treatment and not the treatment given by specialists.

6. Review of Scans and Reports

Never keep a negligent attitude towards the review part. Review of various reports, scans, lab data and tests should be documented. Hospitals can create higher reimbursement through personal MRI images or by examining X ray. You need to make sure that you add a synopsis regarding the information which you have obtained and the way it helped you in the treatment.

7. Signature of the Hospital

It is important to have signature of the hospital in order to get the correct reimbursement. Illegible signature will result in unpaid services by Insurance companies or other Medicare. Always remember to note down the date and time of hospital visits since providers wish to know the exact timing of the patient meeting the physician.

8. Combining Billing

There are times when patients are need to be transferred to another hospital. Patient’s visit in a single day should be covered by the same hospitalists. In these cases it is always a wiser step to not bill separately because second hospital code will automatically get cancelled as both visit have occurred the same day.

Keeping above points in your mind can help you in getting timely and proper reimbursement. Indeed, there are a lot of things that you have to care about. Outsourcing your medical coding and billing needs is a faster and smarter way of getting higher reimbursement by efficient coding and hence streamlined functioning.