Health Information Management

Coding tips from the experts

HIM Connection, January 4, 2011

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Briefings on Coding Compliance Strategies recently asked advisory board members about the best coding advice they ever received. Consider their sage advice:

  • The best advice I ever received is that you should always be able to back up any coding advice you provide with a source authority, such as Coding Clinic or CPT Assistant. Anything else is purely opinion. The biggest challenge facing coders is assigning codes based on documentation. Correct coding is vital in this day and age of RAC and other external audits. —Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS
  • The best advice I ever received is that the codes should reflect the record, and the record should reflect the codes—nothing more and nothing less. You should be able to look at a set of codes and immediately understand what happened to the patient. —William E. Haik, MD
  • The best coding advice I ever received is to always rely on physician documentation, to never assume a physician’s intent, and to look in the Index of Diseases first and then the Table of Diseases when assigning a code. When all else fails, follow the directions. This method of code assignment, while fundamental, has prevented more errors in code assignment than I can ever count. —James S. Kennedy, MD, CCS
Editor’s note: To read more, subscribe to HCPro’s Briefings on Coding Compliance Strategies. Subscribers can find the article in the December issue of their newsletters.



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