C oding is an important element in every chiropractic practice. It not only communicates the services you provide to payers while laying a blueprint for your patients' health and the care they receive, but it also ensures you are paid for the services you render. When you code to send information to a payer, you want to ensure that your office policy is clear that ethical coding is not only smiled upon, but also expected. Make sure that the codes you choose match your documentation, and that your documentation matches your treatment. With audits becoming more prevalent, the choice to code ethically keeps you out of trouble and able to sleep at night. These eight steps help ensure that all coding in your office is correct and complete: 1 . Apply accurate and complete coding at all times. Consistent coding is imperative. Remember, a portion of healthcare data and documentation includes your coding of a visit. Choosing the most appropriate diagnostic, procedure, and related codes should be your standing policy. Never code for convenience or to reduce a fee. Accurately code to represent the work that was performed. 2. Develop and implement coding policies and procedures. Stand firm in your position about correct coding in your office. Ensure that education and training is provided to staff members concerning both CPT and ICD coding. Utilize continuing education and updates to stay abreast of coding changes. Be sure to include policies that prohibit coding practices that misrepresent the patient's conditions or the treatment provided, or are not supported by your documentation. Never misrepresent the facts of a visit, which carries significant consequences. 3. Install coding policies that always complement official coding rules and guidelines. Foster an environment that supports accurate and reliable data, and never participates in false or improper preparation, alteration, or suppression of coded information. Chiropractic coding is relatively simple and involves only a handful of codes. There is no excuse for ignoring or conveniently disregarding the regulations associated with proper coding. 4. Update your coding reference material frequently. Keep the most recent coding resource tools on hand. Stay well informed by attending seminars and we-binars annually that update coding information for chiropractic offices. This includes not only CPT coding information for reporting your procedures, but also diagnosis coding rules for physicians to report on your patients' conditions. 5. Your documentation should easily justify your coding choice. One should be able to identify easily the reason a particular code was chosen from the documentation in the record. If the documentation is for Evaluation and Management coding, it should be easy to determine how you arrived at the code using E/M Documentation Guidelines. Simply make sure that the left hand (your patient's documentation) can explain what the right hand (your coding choice) is doing. 6. Never change or alter reported codes or the narratives of codes so that meanings are misrepresented. Your descriptions for a diagnosis or procedure code in your computer software should accurately reflect the official definition of that code. Changing the description of 97140 in your computer to reflect "trigger point therapy" is not accurate. The code's name is "manual therapy," and includes much more than "trigger point therapy." Select your codes so that your office receives the optimal payment for which it is legally entitled, remembering that it is unethical and illegal to increase payment by means that contradict regulatory guidelines. 7. Don't misrepresent the patient's clinical picture through intentional incorrect coding. The omission of diagnosis or procedure codes, even if accidental, will skew the proper reporting of services. Selecting a lower level CMT or E/M code because it has a lower fee is intentionally misrepresenting your coding. There are much better ways to do this correctly and compliantly. Use a discount medical plan organization (DMPO) like ChiroHealthUSA to legally discount fees. Don't alter your policies to allow cash patients to get 99201 codes as a new patient while everyone who has insurance gets a 99203. 8. Promote internal collaboration by learning more about documentation. As team members, you can be the eyes and ears of the doctor at the front. Internal education for key team members on proper documentation practices, diagnosis coding, and procedure coding allows for "all hands on deck" to ensure accuracy. Billing and collections CAs can do routine audits and reviews of documentation and coding to assist the doctors with accurate reporting. All of us are better than one of us. Your ability to demonstrate ethical principles and professional values in your actions when coding and documenting allows you and each member of your team to function and provide care for your patients with certainty on a daily basis. Implementing these principles creates a pathway for a confident and confusion-free environment. You can truly help others while growing your practice when feeling confident in your ethical standards for coding and care. Suzanne Ball is a Reimbursement Specialist with K.\fC University, specializing in reimbursement and compliance training. Suzanne is known for her amazing cuslomer service and hilling and collections skills. Suzanne can be reached at (855/ TEAKtKMC or infofctjcmcuniversity.com
