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Coding Improvement Module

Coding properly is an important part of any physician practice. This module presents a simple yet systematic methodology for first assessing the appropriateness of current coding and then undertaking an on-going improvement process designed to optimize future coding. At each stage relevant PMC coding resources and tools are incorporated as direct links. Follow these easy steps to improved coding:

  1. Enter your Evaluation and Management (E/M) coding data into the Coding Assessment Tool (login required) to determine how your coding patterns compare to the national Medicare averages for other internal medicine physicians. While not a measure of coding accuracy, this assessment can quickly highlight any variances that might be a red flag to an auditor or be a sign of routine under-coding, a pattern that can erode your income. Because E/M services account for a very high percentage of general internal medicine services, they are a good barometer of coding patterns.

  2. After determining how you compare to your peers, conduct an in-house coding audit (see “How to Complete a Coding Audit”) to investigate any variances from the norm and to assess the accuracy of your current coding. Carefully compile a list of the key problems identified by the audit so you can work on improving them in the future. If you think the audit results suggest a need to study the fundamentals of coding, download our guide: “Coding for Internists: The Basics” (login required) and listen to a presentation "Coding Basics: Getting Paid for What You Do" (login required) including case examples narrated by a coding expert.

  3. As a daily aide to coding future patient encounters use PMC’s two coding reference sheets: “Commonly Used ID-9 codes” and “Evaluation and Management Service Codes…”.These sheets may be printed directly from the webpage or ordered in more durable laminated form from ACP customer service by calling: 800-523-1546, ext. 2600. Carry or place copies in your exam rooms for easy reference.

  4. Periodically repeat the coding audit (step 2 above) to monitor your improvement progress. Audit frequency should be guided by the severity of any identified problems and your success in correcting them. Some practices initially conduct abbreviated sample audits on a weekly basis until improvement is evident and then gradually move to regular quarterly audits.

    Most practices should incorporate quarterly audits into the on-going routine of their operations to avoid slippage, to assure that new physicians are learning to code appropriately, and to stay current with coding changes.

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