EDITOR’S NOTE:
This series is based on the “Developing Facility-Specific Coding Guidelines” which is an AHIMA Practice Brief. This practice brief was updated in December 2023. It also contains an Excel tool to assist you in the development of your coding guidelines.
April begins the third quarter of the federal fiscal year. CPT®, HCPCS, and ICD-10-CM/PCS codes can be updated effective from April 1st. It is also a time when you should be reviewing and updating your facility-specific coding guidelines. Over the next couple of weeks, I will walk you through developing or updating your coding guidelines.
First question – do you have a written version of your coding guidelines? Or do you have notes or a folder of items to remember while you are coding? Written guidelines are useful tools for new coders as well as contracted coding staff. These guidelines promote data consistency which is important because the claims data is utilized to determine reimbursement penalties such as readmission and quality concerns. If you do not have written guidelines, you can start today!
Next question – do you know what inpatient and outpatient procedures you need to code from a reimbursement, chargemaster, or data requirements perspective? The inpatient procedures that are DRG Operating Room procedures are a basic requirement. With regards to the chargemaster, typically specific revenue codes require a CPT/HCPCS code to be sent from the abstract or Health Information Management (HIM) coders. From a data perspective, some departments require coded data such as dialysis, blood transfusions, trauma diagnoses for the Trauma Registry, and cancer diagnoses for the Cancer Registry.
Your assignment this week is to talk with the chargemaster coordinator and identify which revenue codes require HIM to assign codes. Also, talk with department managers regarding their data needs. Talk with other coders about what questions they have about procedures that they are coding and if they have any questions about what to code. Investigate any repetitive issues such as forgetting to code a specific procedure or diagnosis and it is returned based on the claims scrubber.
Another concern is if your state has a data reporting requirement. Review those requirements. I live in Pennsylvania which has the Pennsylvania Healthcare Cost Containment Council (PHC4) which requires quarterly data submission. One data requirement is that all traumatic injuries are reported with an external cause code for how the injury occurred and where it occurred. The data requirement is different than the Official Coding and Reporting Guidelines where you only report the initial occurrence.
Resources:
One of my favorite resources is Insights, distributed by Kodiak. Let me begin by noting that I do not have any affiliation with Kodiak. I
Prior authorization has evolved from a payer checkpoint into a dominant force shaping clinical access, reimbursement, and patient experience. In 2025, hospitals and physician practices
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