CodingNotes

Only Code What Is Documented The physician's job is to document the medical record with accurate descriptions of all services, tests, and procedures exactly as performed and adequately detailed with the patient's symptoms, complaints, conditions, illnesses, and injuries. As a medical coder, it is important that the codes recorded on the medical claim are consistent with the documentation within the medical record. 2 Report Codes in the Correct Order Not only is the coding of diagnoses and procedures as accurately as possible important but coding them in the correct order is also important. The very first code is always the specific reason for the patient's visit even when other diagnosis or symptoms exist or even when multiple procedures are performed. 3 Follow NCCI and MUE Guidelines Medicare and Medicaid have some minor differences regarding coding regulations than other insurance payers. Coders must report units of service based on the National Correct Coding Initiative (NCCI) and Medically Unlikely Edits (MUEs). This is done to prevent reporting multiple services or procedures that should not be billed together because one service or procedure likely includes the other or because it is medically unlikely to be performed on the same patient on the same day. National Correct Coding Initiative (NCCI) was developed by the Centers of Medicare and Medicaid Services (CMS) to prevent inappropriate Medicare and Medicaid payments due to coding errors. There are three types of NCCI edits: Procedure-to-procedure edits: These edits define HCPCS and CPT codes that should not be billed in combination with one another. If these codes are billed together one or both may be denied. Medically unlikely edits: These edits define HCPCS and CPT codes with a certain number of units that are unlikely to be billed if the claim is correct. In some instances, the units of service will be denied that exceed what is considered to be medically necessary. Add-on code edits: These edits prevent the payment of add-on codes that are considered as part of the primary CPT and HCPCS codes.