Ask Caryl: How to Optimize ASC Coding and Remain Compliant

Q: I am worried that my coders may not be coding fully and I am also worried about meeting coding compliance guidelines. What should I do?

Caryl Serbin: With constantly changing regulatory guidelines, it is sometime difficult to remain current on all requirements. I recommend following these six steps to help ensure coding optimization while remaining compliant:

  1. Always employ certified coders.

  2. Ensure that coders have access to current coding editing software; current CPT, ICD-10 and HCPCS reference books; and current coding information available online.

  3. Provide coders with sufficient uninterrupted time to support coding accuracy and the best outcome.

  4. Arrange for continuing education and ensure that coders are kept abreast of all coding changes that affect your ASC.

  5. Perform monthly coding audits. Include in your audits evaluation of accuracy of CPT codes, diagnosis codes, inclusion of appropriate modifiers, implant information (and invoices if required), optimization, compliance (unbundling, over or under coding, etc.) and timeliness of completion.

  6. Contract with an outside firm with ASC auditing experience to perform an annual (at least) coding audit.

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