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What is Medical Coding?

The medical coder’s job is to extract the appropriate billable services from the documentation that has been provided. The coder is given the office notes and/or the operative report as dictated by the physician. From this documentation, the coder identifies any and all billable procedures and assigns the correct diagnosis and procedure codes.

The coder also identifies whether a procedure that is often included with another procedure should be billed on its own (or, unbundled) to allow for additional reimbursement.

To be eligible for unbundling, the documentation must indicate that extra time and effort was required or that a procedure that is normally included in the primary procedure was done at a separate site or time and was necessary to ensure a positive outcome for the patient.

That’s the nuts-and-bolts stuff. To do the job of medical coder well, however, you must be aware that medical coding requires a daily commitment to remaining ethical despite pressures from employers who are looking at the bottom line and don’t understand the laws and procedural mandates a coder must follow.

Physicians have instructed coders to just use the code with the highest revenue potential. This philosophy may be what is best in the short term for the provider’s bottom line, but when an auditor comes around to investigate, that money is going back with interest. So the first order every day for the coder is to be mindful of her ethical duty to the profession, physicians, and patients.

The key to optimal reimbursement is full documentation by the provider (the physician, for example, who sees the patient and performs the procedure) coupled with full extraction, or identification, of billable procedures by the coder. Everyone — from the doc to you, the coder — has to dot every i and cross every t.

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