Standards for Accurate Coding

The standards provided below are to give NYU Faculty Group Practice physicians, medical office staff, and billing staff guidelines for performing their tasks. They are intended to communicate the responsibility and importance of coding accurately. The standards for accurate coding are approved by the Compliance Committee to offer a guide to these professionals in the process.

  • Documentation in the medical record must support the diagnoses and procedure codes selected, and should reflect the medical necessity of the services rendered.
  • Faculty physicians, medical office staff, and billing staff shall use their skills, knowledge of ICD-9-CM and CPT, and any other available resources to correctly select diagnostic and procedural codes. Selection of ICD-9 and CPT codes should only be done by personnel who have been educated in coding. This education is available through the Compliance Department.
  • Faculty physicians, medical office staff, and billing staff shall not change codes or narrative of codes so that the definitions are misrepresented. Nor should diagnoses or procedures be included or excluded because the payment will be affected. Statistical clinical data is an important result of coding.
  • Faculty physicians shall be consulted for clarification when they enter contradictory or ambiguous documentation in the record.
  • The medical office staff or billing staff is a member of the healthcare team and should assist Faculty physicians who are unfamiliar with ICD-9-CM or CPT methodology by suggesting inclusion of diagnoses or procedures when needed to more accurately reflect the occurrence of a service during the encounter.

The Faculty physician, medical office staff, and billing staff are expected to strive for optimal payment to which the provider is legally entitled, but it is unethical and illegal to increase payment by means that contradict compliance plan or regulatory guidelines