Medical Coding and Documentation’s Vital Role

Here’s how revenue cycle management (RCM) plays a part in the process.

It’s no secret that healthcare has undergone historic changes in recent decades — perhaps more than any other industry. Amid the transformation are increasingly complex administrative and regulatory requirements, as well as the 10th revision of the International Classification of Diseases (ICD-10).

Published in 2015, ICD-10 has dramatically impacted medical practices, with its thousands of new codes altering how physicians document and bill for patient encounters. As a result, accurate coding and documentation has become even more vital to provider reimbursement, the lifeblood of your business.  

Why Accurate Medical Coding and Documentation Is Important

The accuracy and adequacy of coding and documentation plays a significant role in the revenue cycle management (RCM) process. As a physician, you are paid for your services based on codes assigned to a patient’s diagnosis and procedures. Your documentation should explain why the patient came in, and what services were provided, so that suitable codes can be assigned to explain why treatment was needed. These codes are submitted together on a claim to inform insurance payers of the treatment you’ve provided.

Accurately coded claims, with supporting documentation can speed up the insurance payment process and ultimately improve your cash flow. Conversely, incorrect or incomplete submitted claims will be denied or rejected, and thus delay reimbursement. In addition, proper coding and documentation can assist with insurance reviews and denial appeals when needed. Equally important, it also can lead to better, more effective patient care, particularly when sharing information with other healthcare providers performing subsequent care on your patients.

Consider an RCM Service for Improved Billing and Documentation

To improve their business performance, many practices turn to an RCM company, which can yield several operational, financial, and patient care benefits. RCM companies often have more knowledge of specific requirements for medical coding, documentation, and compliance. After all, that’s what they do and focus on, as compared to in-house billing staff that may have other responsibilities and less time to stay abreast on coding and documentation changes.

RCM companies install technology and procedures that check for accurate claim data before submission and can quickly identify and recommend corrections for billing errors to avoid delays and denials. They can also have detailed knowledge of the policies and practices of key insurance companies, knowing the intricacies of specific payers’ claim processing, to help accelerate and maximize your reimbursement. Furthermore, they have robust systems to maintain the accessibility, security, privacy, and storage of required documentation.

Implementing a Clinical Documentation Improvement (CDI) Program

What is Clinical Documentation Improvement?

It is a collaborative effort between physicians, practice managers, coders, and clinical documentation specialists working together to facilitate timely and accurate claims processing.

Whether you handle your medical billing in-house or partner with an RCM company, it’s wise to have some form of clinical documentation improvement (CDI) program within your practice.

In addition to maximizing reimbursement and collecting payment faster, a CDI program will help your practice minimize risk by adhering to standards and requirements. In some instances, if documentation is insufficient, incomplete, or incorrect, insurance companies, auditors, and others can take back payment with fines and penalties. This remains critical for every medical practice today.

Get Paid More of What You Deserve

In short, accurate coding and documentation helps prove the medical necessity of treatment provided, leading to payment for your services. It also impacts your reporting and compliance efforts, as well as other medical billing related functions — all of which affect your revenue and cash flow. If you are struggling in this area, or seeking to optimize performance, consider engaging with an RCM outsourcing company or other coding and documentation expert. The success and future of your practice is dependent on it.

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Ronda Tews, CPC, CHC, CCS-P

Ronda Tews, CPC, CHC, CCS-P


Ronda Tews, Certified Professional Coder (CPC), Certified in Healthcare Compliance (CHC), and Certified Coding Specialist-Physician (CCS-P), is the director of billing and coding compliance at Modernizing Medicine® and brings over two decades of robust healthcare compliance experience to the organization. In her current role, she develops and manages the billing and coding compliance program for the company. Ronda performs billing and coding compliance audits among other related functions while maintaining knowledge of current regulatory and compliance guidance.

Prior to her time at Modernizing Medicine, Ronda held various roles such as managing provider compliance for a large health plan in Oklahoma and creating a fraud, waste and abuse program. Ronda’s duties have consisted of conducting E/M audits on physicians and mid-level providers, establishing internal auditing and monitoring, as well as teaching basic coding classes to co-workers and providing E/M documentation training to physicians and mid-level providers. She has also implemented compliance education and training programs, managed the Compliance Report Line as well as compliance auditing and monitoring. Ronda also provided coding and documentation education at Missouri State University to the physician assistant students on an annual basis. Ronda has held various roles such as serving as a Quality Improvement analyst and working as a corporate compliance project manager for a large Mid-Western health system.

Ronda founded the Springfield, MO AAPC chapter where she served as the president and treasurer. She remains very active in the industry as she writes articles for industry publications and can be found speaking at conferences. Connect with Ronda on LinkedIn.

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