As a healthcare professional, selecting the most specific and accurate diagnostic codes is critically important. According to the people at Find-A-Code.com, diagnostic codes reveal important information about a patient’s conditions and the services provided, which affects clinical data analysis, reimbursements, quality metrics, and more. Having best practices around diagnostic code lookup supports accurate coding and, ultimately, better patient care.
Using Reliable Coding References
With frequent code updates and nuances between similar codes, having reputable coding references on hand is essential for accuracy. Online coding tools like coding databases and supervised machine learning systems provide real-time feedback during code search and selection. Unlike static code books, these systems integrate updates, clinical modifiers, payer-specific guidelines, and crosswalks to support the best code choice. Relying solely on memory is risky. To that end, regularly consulting things like updated digital coding tools, application manuals, and coding guidelines resources really helps when it comes to improving precision.
Searching Efficiently
Traversing the vast set of diagnostic codes can be daunting. Developing an efficient search process allows for faster code selection. You could take advantage of digital tools that suggest related codes and provide definitions, and use keywords related to symptoms, diagnoses, and documentation instead of code numbers you do not know. Saving commonly used codes also helps with efficiency after the initial search effort.
Review Code Descriptors Carefully
The descriptive terminology for codes contains meaningful distinctions. Consider the specificity differences between “Type 2 diabetes mellitus with diabetic neuropathy” and “Type 2 diabetes mellitus with polyneuropathy”. Reviewing the complete code descriptions before finalizing code selection reduces any ambiguity and captures details significant to that patient’s situation.
Confirm Code Status and Instructional Notes
Referencing instructional notes provides direction on when and how to apply a code appropriately. It also shows if a code is still active or if it has been deprecated in favor of something else. Using deactivated codes will trigger denials. Checking if there are exclusion criteria before selecting a code prevents having to redo work. Notes also clarify requirements around sequencing multiple codes for concurrent conditions, which affect reimbursement if not followed.
Seek Second Opinions When Needed
Even seasoned coders occasionally come across complicated cases with ambiguous documentation or unusual clinical indicators, making code specificity difficult. Getting an unbiased second opinion from another qualified coding professional if unsure about application helps with accuracy. Finding where uncertainty exists reduces introducing personal coding bias and improves integrity. Having several sets of eyes assessing challenging coding scenarios helps to leverage collective expertise for making better final code selections that fully capture clinical concepts.
Perform Regular Code Audits
Periodically auditing your own diagnostic code choices evaluates consistency with standards and reveals areas for refinement. Self-audits that target often-used diagnostic areas or those prone to revisions are high yield. Auditing a sample of documentation and codes assessed by colleagues also provides peer benchmarking and opportunities for deliberation. Develop individualized improvement initiatives to target common recurring themes from self and peer audits.
Stay Up To Date on Standards
New and revised medical codes get introduced annually with clinical criteria changes that specify when each applies. Dedicate regular time to reading coding update summaries relevant to your practice areas and reference them during lookup. Sign up for update alerts from authoritative coding bodies to stay current. Keeping updated prevents using outdated codes and rules which undermine accuracy.
Conclusion
Following diagnostic coding best practices takes concerted effort yet yields better clinical data, optimizes reimbursement potential, and shows commitment to excellence. Leveraging the latest coding tools, references, and education while emphasizing precision fundamentals will improve the specificity and integrity of diagnostic code lookup. Making these best practices habitual at both individual and institutional levels promotes higher standards for delivering quality care.
