Coding compliance is crucial for all healthcare billing and documentation best practices. It ensures the integrity of medical records, accuracy, and adherence to regulations. This is vital for representing a patient’s health profile accurately, securing proper reimbursements, and avoiding legal issues.
In today’s intricate healthcare environment, maintaining coding compliance is more essential than ever. Recent initiatives from the Department of Justice (DOJ), including the Corporate Whistleblower Awards Pilot Program (CWAPP), highlight the importance of a strong coding compliance strategy.
For coding managers, revenue managers, and compliance officers, it’s critical to understand how to develop and implement an effective coding compliance plan. Accurate medical coding ensures precise documentation of diagnoses, treatments, and patient health journeys. This accuracy benefits clinicians and guarantees that services are properly billed and reimbursed, reducing the risk of revenue loss due to incorrect coding.
I have audited many practices over my 30+ years in healthcare and I can tell you that most practices are still unclear on what Compliance means, let alone how to implement it. I had one provider whose back-office staff wrote off over 2 million dollars in almost two years, because they didn’t know how to appeal claims denials, submit documentation properly, or correct front-end rejections in the Billing pipeline from EMR and Payors. So, they kept writing things off. They never used an Encoder to check correct coding, and no one was a Certified Coder/Biller. So, I uncovered it all and showed him what processes he needed to implement to correct things and become not only compliant, but profitable.
Needless to say, failure to comply can result in audits, large fines, and a damaged reputation, which can severely impact a medical practice or healthcare institution.
Begin At the Beginning – Compliance Guidelines
Establishing and adhering to compliance best practices is crucial in the field of medical coding. While in-house measures are important, outsourcing to experienced coding experts, like ZENMED Solutions, INC., can provide an additional level of precision and expertise. By applying both internal guidelines and external expertise, healthcare organizations can ensure accurate coding, enhance reimbursements, and meet regulatory standards.
Revenue Capture and Coding Accuracy
An effective coding compliance plan assists in preventing issues and capturing all billable services. Numerous healthcare organizations face revenue loss due to undercoding or overlooked opportunities. A comprehensive plan identifies these deficiencies, ensuring precise billing for all services.
Bulletproof Coding by implementing the following:
Regular audits will detect coding issues, ensuring compliance and optimizing revenue. Coding compliance ensures diagnoses, procedures, and data in healthcare meet all relevant rules and guidelines. With ZENMED Solutions, Inc., we can help you maintain compliance in all these areas and improve your ROI.
Why Coding Compliance is essential:
Coding compliance ensures medical coding is accurate, consistent, and meets standards. Correct coding is vital for reimbursement, patient care, and data analysis. Partnering with ZENMED Solutions, INC., ensures confidence in claim submission and handling payer denials or requests.
Key Components of a Compliance Program:
Written Standards: Policies and procedures for coding practices.
Education and Training: Provide ongoing training sessions for coders on current coding guidelines and any updates.
Auditing and Monitoring: Regularly review code to identify and fix issues.
Response: Procedures for addressing coding errors and implementing corrective actions.
Enforcement: Actions taken to ensure that coding practices adhere to established standards and policies.
Common coding and billing risk areas, subject to Office of Inspector General (OIG) investigations and audits:
Charging for items or services that were not delivered or provided as described
Double billing, leading to duplicate payments
Filing claims for equipment, medical supplies, and services that are not deemed reasonable or necessary
Charging for services not covered by insurance
Intentionally using provider identification numbers incorrectly, leading to improper billing practices
Unbundling
Incorrect use of modifiers
Misrepresenting the level of service provided to increase reimbursement/Upcoding
Evaluation and Management (E&M) claims are commonly denied for the following reasons:
Coding discrepancies, such as the code not matching the documentation, and insufficient documentation, which can include the absence of a provider’s signature
There is no documentation regarding the duration and extent of counseling provided.
To remain competitive, medical coding teams should monitor key performance metrics such as MGMA:
MGMA Benchmarks for Medical Coding in 2025
Coding Accuracy Rate >95%
Claim Denial Rate <10%
Days in Accounts Receivable (AR) <30 days
ZENMED Solutions, INC., adheres to performance metrics to ensure compliance across the healthcare landscape for its clients. Non-compliance can result in significant consequences. With increased funding for healthcare fraud detection, agencies such as the OIG and state Medicaid Fraud Control Units are enhancing their activities. Non-compliance may lead to financial penalties and legal actions.
Partnering with a reputable billing company such as ZENMED SOLUTIONS, INC. can enhance your Compliance Program, along with your Revenue Cycle Management (RCM) processes through our advanced AI software, BLISS.
ZENMED Solutions has developed an RCM tool named BLISS – “Barometric Live Intuitive Solution(S).” This intuitive tool can track, categorize, strategize, correct, and learn (TCSCL) the specifics of any practice in real-time, thereby improving all aspects of RCM. We specialize in automating back-office tasks within the healthcare industry. The team at ZENMED Solutions Inc. understands the challenges a practice faces when trying to submit clean claims, which directly impacts the coding and billing departments. Our teams are available to assist with these challenges as needed.
Some of these processes BLISS can assist with include the following:
Correct Procedure code(s)/CPT
Correct Diagnosis code(s)/ CD 10CM /ICD 10PCS
Correct HCPCS codes
Correct Modifier(s)
Keeping abreast of Payer Reimbursement policies and LCD/NCDs for CMS
Date of denial/rejection, if a denial is received, as the payer only allows a certain amount of time to appeal
Description of Denial / Rejection Code(s)- coding error, patient registration error, precertification
Remittance identification number
Charge capture, a crucial step in the revenue cycle.
Automating and tracking claims submissions
Establish a “Culture of Compliance” by prioritizing compliance within the practice’s core principles through well-defined policies, procedures, and leadership support. This approach ensures the protection and integrity of your practice, in other words, “Bulletproof Your Practice”!
“A little knowledge that acts is worth infinitely more than much knowledge that is idle”
ZENMED SOLUTIONS, INC., is based out of Diamond Bar, California and we have over 75 clients around the U.S. If you are tired of sleepless nights worrying about revenue bleeding out of your practice, we can help, take the first step and call us at (844)-307-0806, or email us at: Info@ZenMedInc.com.
RESOURCES:
https://oig.hhs.gov/compliance/general-compliance-program-guidance/
https://www.cms.gov/files/document/01-chapter1-ncci-medicare-policy-manual-2025finalcleanpdf.pdf
ICD-10-CM | Classification of Diseases, Functioning, and Disability | CDC
MBR AAPC/NAMAS
Director of Compliance and Education, ZENMED Solutions INC.
- Struggling with prior authorization denials? Check these quick improvement tips! - June 5, 2025
- CODING COMPLIANCE – BULLETPROOF YOUR PRACTICE - June 4, 2025
- TOP CODING MISTAKES IN 2025 - May 8, 2025