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Once on the job as a coder, establish good communication with your providers long before you notice any coding problems.
As a coder, keep up with all the guidelines, regulations and changes taking place. It's a challenge.
When choosing codes, pay attention to the details in the provider's documentation and choose the most specific codes to describe what is documented. The most specific code is in the details of the service provided. Review the entire documentation to determine the specific reason for the encounter and conditions being treated.
Don't ask "What code do I need to get this claim reimbursed." Remember to code based on documentation, not on which codes an insurance carrier will reimburse on.
Have a good rapport with your providers...let them know that accurate documentation begins with them and keep them informed on what is considered "medical necessity" and what isn't. If they have a diagnosis that doesn't meet a carriers "medical necessity", they can then have the patient sign a waiver.
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