Four Medical Coding Best Practices for 2025 and Beyond

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Posted by Adi Lakshmi Sankara MBA, CPC, CPC-I, CIC, CRC, CPMA, CCS on Oct 16, 2024 5:17:03 PM

 

As many of us already know, it’s a tough time to work in healthcare. Payment cuts coupled with ongoing healthcare staffing shortages exacerbate an already tense environment. Hiring challenges are especially persistent within revenue cycle management departments held accountable for meeting and exceeding medical coding productivity and quality standards. It’s these Key Performance Indicators (KPIs) on which healthcare organizations rely to promote smooth cashflow, revenue integrity, and a profitable operating margin. To be successful, revenue cycle managers—and the revenue cycle management outsource vendors with whom they partner—must follow several best practices for hiring, training, and monitoring medical coding staff members.

In the following article, Adi Lakshmi, MBA, CPC, CPC-I, CIC, CRC, CPMA, CCS, associate vice president at Global Healthcare Resources, shares four of her best practices and strategies. 

 

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1. Monitor your denial rate closely. "Of all of the key performance indicators that reflect health of your revenue cycle, your denial rate is likely the most important because it provides immediate insight into financial performance," says Lakshmi. "Best practice is a denial rate that’s less than 5%, but you also need to understand why each denial occurs," she adds. 

For example, is it a medical coding error? Problem with clinical documentation? Lack of prior authorization? Something else? Even once you identify what you think is the reason why the denial occurred, you still might need to dig more deeply. For example, if it’s a coding error, why is the coder making errors? Does he or she need education and training? Are they overwhelmed and burned out? Is a glitch in your electronic health record? 

“You need to get down to the root cause,” she adds. “Monitoring your denials is the only way to promote high-quality coding and accurate reimbursement.”

2. Perform medical coding gap analyses. Today’s healthcare staffing shortages mean some organizations may need to hire coders of varying skill levels and experience. The same is true for revenue cycle management outsource vendors. Performing a detailed gap analysis ensures you match coders and coding projects appropriately. The goal? To maintain medical coding accuracy and quality. Here are some questions to consider as part of that analysis:

  • What procedures and diagnoses will the medical coder code?
  • Are there any internal coding guidelines that apply?
  • Will the medical coder read the record and assign codes, or will they validate codes already assigned?
  • Will the medical coder use any other forms of artificial intelligence in the revenue cycle?

    “Base the analysis on the specific scope of work,” says Lakshmi. “Then deliver education to fill the gaps and assess again. After that, you can move the coder slowly into a live environment to ensure their quality remains consistent. And if you’re working with a revenue cycle management outsource company, ensure it does the same.”

3. Leverage all coding resources.  Examples might include education for medical coders, cheat sheets, and other resources to help coders focus and be successful. It also includes internal coding edits in your electronic health record that help coders stay abreast of important changes. For example, an edit could alert a coder to confirm whether a code is accurate based on its newly revised description. 

When it comes to annual coding updates, don’t wait to provide medical coder education. “By the end of December, start prepping coders for CPT changes that take effect January 1,” says Lakshmi. “Similarly, by the end of September, make sure coders understand ICD-10-CM changes effective October 1. It’s about being proactive and deliberate in your approach to medical coder education and ensuring your revenue cycle management outsource vendor is on the same page as well.”

4. Provide coders with quality review feedback.  Reviews based on prospective audits (i.e., before claim submission during the quality assurance review process) as well as retrospective audits (i.e., after claim submission and denials occur) are to be included. “Coders need this feedback daily” says Lakshmi. “Without timely feedback, coders will continue to make the same mistakes. If you partner with an outsource revenue cycle management vendor, be sure to inquire about how and when it provides medical coders with individual feedback on their performance.”

Looking ahead. Healthcare is a tough industry, and the healthcare staffing challenges everyone faces likely won’t abate anytime soon. Facing these challenges while simultaneously promoting revenue cycle integrity and efficiency requires today’s managers to take a mindful approach to hiring, training, and ongoing monitoring. Learn how Global Healthcare Resources can help augment your strategy. 

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Adi Lakshmi Sankara MBA, CPC, CPC-I, CIC, CRC, CPMA, CCS

Adi Lakshmi Sankara MBA, CPC, CPC-I, CIC, CRC, CPMA, CCS

Adi Lakshmi Sankara holds her MBA, CPC, CPC-I, CIC, CRC, CPMA, CCS distinctions and is an AAPC Approved ICD-10 Trainer and NLP Practitioner. In addition, she is AM certified through TAFE University. She has over 28 years of experience in medical coding, auditing, and clinical documentation. She has advanced revenue cycle and medical coding expertise for multiple specialties, most notably E/M, ED, Surgery, IP-DRG, HCC, Clinical Documentation Improvement, and Physician/Hospital coding. Over the years, she has presented at numerous educational conferences to providers covering proper documentation requirements for services rendered and has spoken at multiple AAPC International Coding Conferences. As Associate Vice President of Coding at Global Healthcare Resource, Adi is responsible for assisting medical coding operations and resource utilization and improving productivity and operational efficiencies for our valued partners.