Coders Play an Important Role in Revenue Cycle Management and Compliance Efforts

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coders play an important role in

The medical field is chockfull of crucial non-clinical roles. Even though the general public is familiar with medical billers, coders rarely get mentioned. However, coders play an important role in the healthcare system.

For starters, they translate all that medical lingo into universal medical codes for accurate medical billing. That’s pretty big in itself but they also do a damn good job when it comes to identifying devastating non-compliance issues.

With this post, we’ll explore why coders play an important role in the healthcare system and what makes them an indispensable part of the medical billing process. First, we’ll focus on what revenue cycle management (RCM) and compliance efforts are, and address both the respective roles of coders and medical billers 

What are revenue cycle management and compliance?

Revenue cycle management is the process of tracking patient care from the beginning to the very end by leveraging medical billing. 

In other words, RCM is a link between the clinical aspect of healthcare and the business side.

It connects administrative data like the patient’s insurance provider with the treatment that the patient has received.

Another important aspect of RCM is communication with insurance companies. As the patient schedules the appointment, the staff checks their coverage before they even walk into the medical practice.

Once the treatment is complete, medical coders step in to categorize the nature of the treatment. The summary is then passed on from the hospital to the insurance provider. 

On the other hand, compliance efforts refer to monitoring rules, laws, and regulations to protect the healthcare provider from noncompliance and risks by identifying issues in compliance management functions.

Medical billers and coders in RCM

Both billers and coders are deeply familiar with coding and billing guidelines and reimbursement policies. However, what they do is very different.

What medical billers do

Medical billers prepare billing claims and submit them to insurance carriers. They are responsible for ensuring that the healthcare provider is correctly reimbursed for the medical services they provide. After the patient is done with their appointment, the healthcare provider assigns procedure codes to the procedure, which are used by insurance companies to assess the associated coverage.

Medical billers are involved in multiple processes, such as:

1. Patient registration
2. Verification of eligibility and benefits
3. Charge entry
4. Posting payments
5. Rejection corrections
6. Denial management
7. Account receivable management

Any incorrect information in the claims to insurance carriers will result in denied payments. 

What medical coders do

In short, medical coding refers to converting important, yet complex medical information into uniform medical codes. 

These codes are then used for documenting medical records and for billing purposes. 

This system ensures a seamless transfer of medical records along with a more efficient way to track the health records of patients. 

Coders work behind the scenes from the start of the revenue cycle. Healthcare providers send detailed medical reports to coders which include the patient’s condition and diagnosis as well as any prescription. Coders then translate all that information into alphanumeric codes and ensure that the medical records are properly documented and the billing information is accurate. 

Any errors in the coding can have severe consequences such as:

1. Claim denials
2. HIPAA violations
3. Loss of revenue
4. Lawsuits
50 Federal fines

When a claim gets denied by the insurance provider, the entire revenue stream takes a massive hit. To make matters worse, it takes a lot of time and effort to identify the issue and resubmit the claim. As the cherry on top, that also doesn’t ensure that the claim is paid in total as insurance providers might only agree to make a partial payment.

It’s also important to note this doesn’t only affect the healthcare provider and their bottom line, The patient care itself is compromised too. In turn, patients that were affected by coding errors can file for malpractice. So on top of the direct disruption in the revenue stream, a hospital, for example, might also end up paying hefty fines and legal fees.

Hence, coders play an important role in discovering non-compliance issues. 

The link between coders and compliance efforts

Coders handle multiple documents and review them to determine if the codes check out. This is why they can spot a wide variety of compliance problems. 

In the revenue cycle, for example, coders can identify omissions of legitimate charges or discover that the charges themselves are incorrect. They might uncover incorrect terminology or the incorrect use of abbreviations in medical records.

Additionally, they might even run into a case of clinical plagiarism which doctors sometimes resort to. For instance, a doctor might copy and paste content from another doctor’s record and include it in their record as if they ordered or performed that work. These are all issues that could lead to liability or non-compliance. 

Coders can recognize these issues and raise a concern, which can then further be investigated by professionals dealing with compliance and risk management. Some examples of risk management issues that coders can help discover include:

Untimely preparations of reports

The preparation of reports can easily become a major risk management problem. For example, if there is a complication during surgery and operative notes aren’t dictated 30 to 40 days until the patient is discharged, there will be a big problem if the case goes to court. 

The surgeon might have a harder time proving that he could accurately describe the procedure because the report is old and they had completed additional surgeries before writing it. 

‘’Biting’’ comments in medical reports

Any information in medical reports that don’t concern the patients are referred to by the coders as ‘’biting’’ comments. For example, a physician might call out a fellow physician for poor performance or insufficient preparation, or a nurse might detail abusive language from the physician.

Coders can then call attention to these progress notes so the risk management team can get involved in mitigating the problem.

Falls and injuries that aren’t reported to risk management

During treatment, it’s not uncommon for a patient to experience injuries or falls. Nevertheless, these events must be reported to risk management. The role of coders here is to report these instances and forward the information to risk management.

Nursing should, in theory, report all incidents. The reality is a bit different as mistakes can sometimes happen. If a coder did report the injury, risk management has the necessary documentation to contact the employees or the patient in a timely fashion after the incident.

The power of the code

While in most cases, codes might look like complete gibberish to mere mortals, they are at the core of medical billing. Coders and billers use them to ensure that you get properly charged for your treatment. 

Both medical billers and coders play an important role in ensuring that all payments check out. But more importantly, they protect the patients from getting overcharged.

Furthermore, these medical specialists can help mitigate non-compliance issues because they’re right in the middle of the action. This is where they truly shine and where their skills come in. A mediocre coder might not have enough time to focus on risk management problems. But the one who is skilled enough to translate medical procedures into medical codes that also keeps an eye on compliance, risk management, and the revenue cycle is a force to be reckoned with.

If you needed additional persuading as to why coders play an important role in healthcare in general, not just in medical billing – this is it.