Tip of the week: Follow these steps to ensure accurate coding

Hospitalist program revenue depends on accurate coding. To ensure correct coding, hospitalist program managers should follow these tips:

  • Attend educational sessions focused on coding and billing for the common services the program provides.
  • Schedule routine auditing by peers or an internal auditor.
  • Engage an independent outside source to review coding and billing practices every three to five years.
  • Follow reviews with a plan for corrective action, education, and refunds to payers when appropriate. Educate hospitalists regarding areas that need improvement and engage the program in a corrective action process until it adequately improves.
  • Familiarize yourself with effective ways to express medical necessity information in notes, dictation, and the electronic medical record.
  • Avoid “cloned” documentation or information that is automatically brought forward from a previous note or encounter. 

This week’s tip is from The Hospitalist Program Management Guide, Second Edition by Kenneth G. Simone, DO and Jeffrey R. Dichter, MD, FACP.