EHR Medical Coding Recommendations

Medical coding can be complex. There are nearly 100,000 different codes used to classify different diagnoses and procedures, and they’re updated annually. If a claim sent to insurance isn’t coded properly, reimbursement for the services can be delayed and negatively impact a medical practice’s revenue cycle management. Alternatively, medical practices may be missing out on billing opportunities if certain codes aren’t entered.

In this article, we’ll dive into the profession of medical coding, specific types of codes, and how software tools can assist medical coding and billing specialists.

What is medical coding?

Medical coding occurs when a healthcare professional or medical coder translates diagnostic and procedural information into a universal set of alphanumeric codes. These codes correspond with a patient’s diagnosis, treatment, medical necessity, or other procedural information related to the visit. Medical coders examine a patient’s medical record, which includes their doctor’s notes, laboratory tests, diagnostic information, requested imaging studies, and any other relevant sources to verify what services were provided.

The two most common medical coding classifications are the International Classification of Diseases (ICD) and the Current Procedural Terminology (CPT). These codes are entered into an electronic health record system to promote proper medical record keeping and streamlined claims and billing processes. 

To prevent medical coding errors, many healthcare organizations rely on electronic health record (EHR) software with built-in coding recommendations or they outsource medical coding, billing, and revenue cycle management services. Proper medical coding avoids insurance payment denials and helps medical practices keep control of their cash flow.

What are EHR ICD-10 codes?

The International Classification of Diseases 10th Revision (ICD-10) was authorized for publication by the World Health Organization in 1999 to help classify diseases and injuries. ICD-10 codes are entered by healthcare personnel or medical coders who assign a code to describe a patient’s diagnosis. 

These codes are used by medical professionals to track a patient’s medical history. Once the codes are entered into an electronic health record (EHR) system, they are used to generate claims for insurance or patient bills. ICD-10 codes are also used by insurers and, in some cases, public health officials to conduct research or general surveillance of certain illnesses and injuries within a population. There are currently more than 70,000 ICD-10 codes in use as of 2022.

What are EHR CPT codes?

Current Procedural Terminology (CPT) codes are a standardized set of codes used to classify medical procedures. CPT codes are added to a patient’s medical record to track a history of procedures. They are also used to generate insurance claims for reimbursement. On a macro scale, CPT codes may be used by public health professionals to track the incidence of certain medical procedures and monitor healthcare trends. There are currently 10,000 CPT codes in use, according to the American Medical Association, though this number changes on an annual basis.

How does EHR Software Recommend CPT and ICD-10 Codes?

Some EHR software solutions, including Benchmark Solutions EHR, have a built-in CPT and ICD-10 code recommendation tool, with an embedded search function that makes finding codes easier. Medical practices can also customize coding templates that help streamline the billing process. For example, a practice may have a template for routine exams—such as an annual physical—with built-in standard code recommendations to make it easier to process the encounter. Medical coders can also use the EHR’s recommendation feature to pull up a preferred list of codes based on a patient’s medical history or diagnosis.

Medical coding recommendations, pre-made templates, and integration with each patient’s history makes coding more streamlined and reduces errors.

How do EHR coding recommendations benefit your practice?

EHR coding recommendations save medical practices time entering CPT and ICD-10 codes. These built-in tools also reduce the amount of data entry and medical coding errors. EHR software that doesn’t support coding recommendations increases the amount of manual data entry performed, impacting a practice’s labor and overhead costs. Coding errors can also negatively influence reimbursement and revenue cycle management. EHR systems that feature coding recommendations help streamline the billing process by improving insurance claims acceptance rates.

Are you ready to streamline your medical coding process?

The average clinician spends half their day coding encounters and writing case notes. Save time with Benchmark EHR’s integrated coding recommendations.

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