“Coding” generally means the method by which a patient’s level of service or charge for service is determined. In other words, it (directly) states how much work you did and (indirectly) how much you should get paid for it.
Like everything else in medicine, coding is complex and often confusing. (In 1997, a general audit of Medicare charts showed that up to 75% were coded incorrectly.) However, it is essential to a physician’s survival in practice. Employers, partners, insurance companies, and staff will all be evaluating your ability to code correctly. Improper coding could result in audits, refusal of payment by insurance companies, delays in payment for services, lack of promotion, unwillingness of others to partner with you, and possibly charges of fraud.
Unfortunately, the business aspect of medicine is not well taught to most residents. If coding is taught to residents, it may be a slanted or skewed view of coding and may not reflect practices in the real world. Many residency faculty members decided to go into teaching for the specific purpose of avoiding the business aspect of medicine. Others may have not had to deal with coding issues in so long that they may no longer be up to date on current coding procedures.
There is a precise method by which the correct code is chosen for each patient visit. Similar to the components of a History and Physical (chief complaint, history of present illness, family history, etc.), there is a standard universal format for coding. The criteria for a 99213 visit inNew Yorkis the same a 99213 visit inCalifornia.
Medical Coding and Billing For Residents 