The Role of Coding Compliance in Health Claims Reimbursement


Coders are an often-overlooked member of the healthcare team. But without their expertise, both the patient and practice would suffer.


blog image

Compliance is certainly a hot topic these days in many industries. In healthcare, it’s a cause for angst throughout the revenue cycle, from patient care to billing and reimbursements. Medical coders have a never-ending task trying to keep up with changing laws, regulations, and medical codes, which makes it difficult to remain compliant. Non-compliance can not only affect claim reimbursements and cash flow, it can also have other negative consequences for the practice or hospital. Here are some compliance strategies to keep you in good standing with regulators as well as improve your bottom line.

Importance of accurate and compliant coding

Coders tell the story of a patient’s journey through the healthcare system. For proper patient care, billing, and claim reimbursements, it’s imperative that the coding is accurate. However, an Office of the Inspector General (OIG) audit of the Health Care Financing Administration (HCFA) revealed errors in 30% of all claims paid by the HCFA. Half were due to insufficient or inaccurate documentation.

HCFA’s action plan to address the problems identified by the OIG audit includes the following measures:

  • Increased payment reviews of medical necessity and medical record documentation supporting claims
  • Overpayment recovery
  • Providers identified by the audit as submitting improper claims will be targeted for more extensive investigation
  • Demand more documentation from providers who submit claims

Those measures mean that the provider’s documentation and coding will be under closer scrutiny, highlighting the need for accuracy, completeness, and compliance with regulations.

The role of coders in the revenue cycle

Coders are key components of the healthcare revenue cycle. They translate a patient’s story from initial scheduling through their healthcare experience to final payments. By using standardized codes and coding guidelines to translate the documentation, coders help support a healthcare facility’s quality compliance. Compliant coding streamlines the revenue cycle, reduces claim disputes and denials, and ensures adherence to governmental healthcare regulations.

Compliant coding strategies for improved reimbursements

Compliant coding is important in every step of the revenue cycle. Here are some coding best practices for optimizing reimbursements and revenue:

  • Improve clinical documentation quality. Coders can’t code a patient encounter correctly without complete and accurate information. A recent study found that EHR documentation and what actually happened during a clinical encounter only matched between 38% and 53% of the time. To strengthen coding’s role in compliance, hospitals and healthcare systems should invest in a clinical documentation quality manager.
  • Use technology to improve documentation and coding. Technology can streamline and optimize claims management and reimbursement. It can help coders prioritize their work to focus on accounts that will have the biggest impact on the organization. Computer-assisted coding (CAC) solutions can take information from patient records and push it to the coders, so they can focus on creating a patient’s story of their healthcare journey.
  • Educate providers. Education can help break down the silos between providers and compliance staff, as well as coders and clinical documentation improvement specialists. Coders and compliance staff need to teach physicians why they need to document a certain way.

Coders play a crucial role in not only a practice’s revenue cycle but also the quality of patient care. Make sure they know they are an important part of the healthcare team.

Need help with your coding compliance and quality? Learn more about TruBridge Medical Coding Service.

Written by Vanessa Brumfield
TruBridge Director of Coding

Top