Best Practices Overall for Coding (2024)

BEST PRACTICES OVERALL FOR CODING

The goal is for providers to submit claims/encounters with coding that administratively captures all required HEDIS data through claims. This decreases or removes the need for medical record review and improves timeliness of closing gaps in care reflected in your monthly reports.

• Submit accurate claim/encounter data for each and every service rendered
• Ensure medical record documentation reflects all services billed
• Revise super bills (paper coding forms) to capture applicable coding requirements
• Submit claim/encounter data on a timely basis
• Incorporate templates and ticklers into your EMR system as a reminder of HEDIS recommended screenings
• Develop EMR standing order sets capturing applicable coding requirements (e.g. CPT II codes)
• Have a designated office staffer(s) tasked to gathering and submitting supplemental data

Best Practices for Measures with CPT Category II Codes

Did you know that adding modifier 1P, 2P, 3P or 8P to Quality review services disqualifies you from receiving credit for Quality measures? To receive credit for Quality services reviewed but not performed, you can report a CPT Category II code without a modifier. For example:

National Committee for Quality Assurance (NCQA) General Guideline on Code Modifiers:

Modifiers are two-digit extensions that, when added to CPT or HCPCS codes, provide additional information about a service or procedure. Exclude any CPT Category II code in conjunction with a 1P, 2P, 3P or 8P modifier code (CPT CAT II Modifier Value Set) from HEDIS reporting. These modifiers indicate the service did not occur. In the Value Set Directory, CPT Category II codes are identified in the Code System column as “CPT-CAT-II.”

BEST PRACTICES FOR MEASURES WITH TELEHEALTH CODES

• Identify staff to conduct telehealth interactions with patients
• Develop protocols so that staff can triage and assess patients quickly
• Practice using technology first with other staff before you use with a patient
• Create a backup plan and establish protocols in case escalation of care is required or technology fails
• Document a complete and accurate record of all telemedicine services performed in member's medical record based on your interaction, including any assessments or treatment plans at the time of the visits
• Check in with patients to find out if and where the trouble areas are for them

NOTE: By coding and billing modifiers 95 or GT with a covered procedure code, the provider is certifying that the member was present at an originating site when the provider furnished the telemedicine service.

• Identify barriers and provide solutions i.e., transportation, extended clinic hours, immunization clinics
• Identify existing barriers (i.e., access to care, cost, anxiety, embarrassment and fear, attitudes and beliefs, level of education, race/ethnicity, income and insurance coverage) to implement policy, procedural changes to increase the rate of mammography, cervical cancer screenings, and other preventive screenings services
• Use reminder notifications that immunizations are due and recall notifications that immunizations are past due
• Develop strategies to prevent missed opportunities for preventive screenings and services (i.e., standing orders provider education, provider reminder and recall systems)
• Increase community demand to promote preventive services and screenings through patient reminders, small or mass media, group and one-on-one education
• Conduct chart review to identify evidence of previous screening, services or exclusion
• Utilize patient-focused educational materials availability through Horizon Healthy Journey Program i.e. breast cancer screening reminder cards
• Utilize open-ended questioning when engaging patient. Recommend colonoscopy first and FOBT as an alternative. Ask, “Which one do you choose?” (Motivational Interviewing)
• Complete pre-visit planning to identify all gaps and call the patient to come in
• Coordinate lab testing prior to the office visit so that results can be reviewed and treatment plans adjusted as needed
• Repeat abnormal lab tests later in the year to assess for improvement
• Communicate with members and other treating providers to ensure all tests are completed and documented results are shared with the team
• Establish process for obtaining laboratory results from other providers participating in the patient's care
• Hardwire values with laboratory procedure code claim submission for in office laboratory services and partner facilities
• Refer uncontrolled diabetics to clinic care coordinator, if available, or case management services
• Create diabetes measures computer screen savers
• Host diabetes day education and screening
• Conduct chart review to identify exclusions of criteria for gestational or steroid-induced diabetes
• Report zero charge CPT II code with a date of service no more than seven days from the date of the test result
• Determine reason for open care gaps
• Establish agreements between practice and specialists to provide arrangements for the exchange of information. Indicate the type of information that will be provided when referring patients and expectations regarding timeliness and content of response from the specialist
• Establish standing orders for annually laboratory or in office CLIA waived testing
• Repeat BP reading during an office if the initial readings are high; monitor BP status at each visit and adjust medications as needed for control