How to identify EHR requirements for medical coding

EHRs make it difficult for practices to say they are not ready to meet medical coding requirements. After all, an electronic system can be updated for the latest requirements in a matter of hours. For some practice managers, the biggest question is, “How do I identify medical coding requirements for the practice’s EHR system?” Many of the same tools used for coding requirements before EHR systems were common can be used to help identify EHR requirements.

Watch CMS guidelines

Unfortunately, every insurance carrier’s requirements are not equal. However, CMS tends to be the baseline for any insurance coding policy. Therefore, watching CMS’s website for coding information, such as updates to National Correct Coding Initiatives (NCCI Edits), EDI Transactions, and Healthcare Common Procedure Coding System (HCPCS), makes it easier to stay up to date on any coding changes your EHR should handle.

Utilize CPT manuals

A new CPT manual is released each year. Most include helpful tips about which codes you can and cannot bill with. Some also include suggestions about which modifiers or diagnosis codes are or are not compatible. Sometimes slogging through CMS can be time consuming, so using a CPT manual at the beginning of the year is a great starting point to check current rules.

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Consider your most commonly billed insurance carriers

Many of the insurance carriers your practice commonly bills allow you to sign up for alerts regarding policy changes. Make sure multiple people in your practice receive the updates to ensure that you do not miss anything. Specialty-specific rules are common, especially for non-Medicare and Medicaid carriers. Look for policies specific to the practice’s specialty or code-specific policies to ensure that you are up to date on the correct uses for each CPT. Once you have an efficient system for identifying coding changes, you can use these to assess your existing health IT or to implement new systems.

ICD-9, ICD-10…

ICD-10 is coming. While some carriers may accept ICD-10 now, others insist on using ICD-9 until the official change. Stay updated on what your commonly billed carriers use as this will dictate the requirements you have for your EHR system. As always, testing claims is a useful tool. Any time a coding change is implemented in your system (for instance, when ICD-10 goes into full effect), you should put out a select number of claims with that coding to several different carriers. See what happens. If they are denied, additional research with the carrier is warranted.

Find the right system

Find a system that can be easily updated with new coding requirements. Similarly, consider a system that is customizable. A good EHR will suggest diagnosis codes and CPT codes based on visit details. In addition, a good EHR will warn you about possible conflicts when you enter charges. For example, a warning such as “CPT X is considered bundled with CPT Y per CMS guidelines” should be available to prevent coding errors.

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Samantha Williams

About the author…

Samantha Williams’ EHR expertise stems from three years of medical billing for a large physician practice in New York City. She trains new hires to use a medical billing and EHR system and writes appeals for denied neurosurgical procedures, resulting in additional insurance payment.

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Samantha Williams