Coding

Objective

To ensure that CUIMC clinicians submit accurate diagnostic and procedure codes for services billed in their names.

This coding policy applies generally to CUIMC clinicians in most clinical departments. However, for some clinical departments, the OFBC has approved code selection using an abstraction method or similar process. In certain departments and divisions, non-physician coding may have been approved by OFBC and CUIMC leadership.

Policy

  1. With limited exceptions, each CUIMC clinician is responsible for the CPT-4 and ICD-10 codes for services billed under his or her name and billing number. CUIMC clinicians must be knowledgeable about the codes applicable to their practice.
  2. The department compliance staff monitors whether the codes chosen match the medical record documentation for that code in order to ensure that accurate codes are billed.
  3. The department compliance staff is responsible for notifying the CUIMC clinician when there is possible discrepancy between the code chosen by the CUIMC clinician and the staff’s determination of the appropriate code for the service. Such notification policies and processes are established by the routine auditing schedules for individual departments.
  4. For Departments given permission for coders to review and select codes for the providers a routine audit by departmental compliance staff is required. These processes must be administered carefully and reviewed on a routine, consistent basis.
  5. Departments that employ coders will direct their coders to share their coding findings with their departmental compliance staff on a regular basis.

 

 

 

 

 

Office for Billing Compliance
Policy#: 10026
Original Date of Issue: 1996
Revised: 3/22/2023
Reviewed: 3/1/2024