An Institute of Medical Coding guide to understanding how accurate documentation supports sound coding decisions.
How codes connect to claims
A claim communicates the services provided and the diagnoses that support them. Payers may assess code validity, coverage, documentation, medical necessity and other billing requirements. A coding mistake can contribute to a rejection, denial or request for review, although one code is not the only possible cause.
Common points of failure
An outdated code, missing required specificity, incorrect sequence, unsupported diagnosis or mismatch between a service and its documentation can create a problem. Other issues, including eligibility and authorization, may occur even when the codes are correct.
What to check before submission
Confirm the correct code set for the date and setting, read relevant instructions, compare codes with the signed record and review the claim for missing or inconsistent details. Follow the payer and organization rules applicable to the claim.
If a claim is denied
Read the actual denial reason and compare it with the submitted claim and medical record. A team may correct an error, supply supporting documentation or follow the appeal process when appropriate. Do not change a diagnosis merely to obtain payment.
