While a staff member may aid with coding, the physician — who is accountable to the government and other payers — must review the codes for accuracy prior to submitting them for billing. Watch for these red flags in your practice’s coding habits:
- Within a group setting, inconsistent coding among partners.
- Coding level 5 services and not preventive medicine codes for annual physicals.
- Upcoding on stable chronic conditions.
- Missing physician signatures for lab and/or test results ordered by a physician assistant, nurse practitioner, or physician.
- Use of words such as “maybe,” “perhaps,” “probably,” or “rule out” instead of signs and symptoms.
- Use of symbols or shorthand. (Be sure to have a list of what the symbols or shorthand means in your office. Negative symbols without elaboration are not considered sufficient documentation.)
- Lack of specificity about what you are reviewing. (Review of systems as unremarkable is insufficient data to support that a review was completed.)
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