Chapter 10 Reality Check Billing and Reimbursement

Coding Guidelines are the foundation for all fair and accurate coding practices around the United States and world. While all coders love to have all the guidelines written clearly in black and white, there are many gray areas that leave room for much discussion. This is where new coders often over code, under code, unbundle, bundle, code too much, or too little. If you’re an outpatient coder, for example, you quickly learn you can’t code anything a provider states with the words ‘likely, should be, would be, could be probable, etc.’ Coding Guidelines are the key to a coder’s success, and the key to a successful practice!

When Tammy started coding, she paid attention to every detail in the patient’s chart. She followed coding guidelines and coded only those conditions that were medically managed. Tammy’s coding department was under a lot of pressure to code high volumes of charts. In order to save time, sometimes Tammy coded a diagnosis that that did not necessarily support a procedure, and at times she unbundled services. While it wasn’t an intentional attempt to commit fraud, Tammy was committing fraud.

If you were the coding manager of Tammy’s department, discuss how you might avoid these fraudulent events.

Put your comments in a word document, I’m looking for between 2 and 3 paragraph

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As a medical professor responsible for creating assignments and evaluating the performance of medical college students, it is imperative to emphasize the importance of following coding guidelines. The guidelines serve as the foundation for accurate coding practices and help to ensure a successful practice. In the following answer, we will discuss how to avoid fraudulent events in the coding department.


As the coding manager of Tammy’s department, the first step I would take is to provide comprehensive training on the importance of following coding guidelines. It is crucial to educate the coding team on the implications of fraudulent coding practices and how it can have severe consequences for the organization and the patients. Moreover, it would be necessary to provide clear instructions and examples of correct coding practices, which would aid in avoiding fraudulent activities.

The second step would be to implement a comprehensive auditing and monitoring program that would track the coding activity of each team member. The program should review the coding accuracy and appropriateness, along with ensuring adherence to coding guidelines. The program should detect any uncharacteristic coding practices promptly. In doing so, it would enable us to identify instances of potential fraud and brainstorm strategies to prevent it from occurring in the future.

Lastly, it’s imperative to establish an organizational culture that promotes ethical behavior. This can be accomplished by instilling a sense of accountability and responsibility amongst the coding team. Additionally, it would be necessary to provide incentives for good coding practices and promote a work environment where ethics and integrity are highly valued.

In conclusion, avoiding fraudulent coding practices requires a proactive approach that focuses on training, auditing, and monitoring, and establishing an organizational culture that promotes ethical practices. By implementing these strategies, we can ensure the long-term success of the coding department.

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