Medical Coding Accuracy: Maximizing Reimbursement
How to code accurately so you are paid correctly for the care you provide, avoid denials and stay compliant.
Accurate coding means being paid correctly for the care you actually provided: not less, and not more. Errors in either direction cost money, whether through lost revenue, denied claims or audit exposure.
Common Coding Errors
Undercoding
- Leaves legitimate revenue unclaimed
- Doesn't reflect the complexity of the visit
- Often comes from habit, such as defaulting to the same E/M level
Overcoding
- Creates compliance risk
- Increases audit exposure
- Can lead to repayment demands or fraud allegations
Incorrect or Missing Modifiers
- Claim denials
- Reduced payments
- Rework for your billing staff
Diagnosis Problems
- Unspecified ICD-10 codes where a more specific one is supported
- Diagnoses that don't support the medical necessity of the service billed
Coding in Psychiatric Practice
Psychiatric billing has its own pitfalls:
- Evaluations: psychiatric diagnostic evaluation codes (90791 without medical services, 90792 with medical services) are distinct from E/M codes.
- Medication management: follow-ups are usually billed as E/M visits, based on medical decision-making or total time.
- Psychotherapy add-ons: when psychotherapy is provided in the same visit as an E/M service, add-on codes (90833, 90836, 90838) require separately documented psychotherapy time.
- Telehealth: place-of-service codes and modifiers vary by payer, so check each payer's current rules.
Improving Accuracy
Documentation
- Complete, specific notes written at the time of the visit
- Medical necessity clearly stated
- All diagnoses addressed in the visit captured
- Time documented whenever you bill by time
Process
- Review codes before the note is signed, not after the claim is denied
- Check every denial for its reason and look for patterns
- Keep your payer-specific rules written down where staff can find them
Training
- Regular coder and provider education
- Annual review of CPT and ICD-10 changes
- Periodic internal audits of a sample of notes
How Jogaza Helps
Jogaza EHR keeps diagnoses (ICD-10) and CPT codes in the note, ready for the claim, and flags undocumented sections before signing. On the Professional plan, claims are created and submitted through Office Ally, and claim status is reconciled from Office Ally's 999, 277CA and 835 reports, so you can see which claims were accepted, rejected or paid.
Jogaza doesn't choose codes for you. Code selection stays with the clinician and your billing team.