Why Risk Adjustment Coding Is Important

ICD-10-CM coding has historically taken a back seat to CPT coding when it comes to professional billing. ICD-10-CM is used for a variety of reasons such as tracking disease process and spread of diseases but most importantly it’s been used to drive medical necessity together CPT paid. With productivity standards in coding and CPTs being the “money” codes, ICD-10-CM has really taken a back seat.  Coders will sometimes neglect guidelines or select codes that are less specific just to cut down on time and meet their productivity standards.

Much of the health care industry is still in the fee-for-service mindset. An example of fee-for-service is a patient that goes in to see their Primary Care Physician for management of chronic conditions and the Physician gets a fixed fee regardless of how well or how poorly that condition is managed. If the patient is compliant and keeps their conditions under control, the provider gets a set fee. If the patient doesn’t understand their management plan and has severe exacerbations that land them in the hospital, that provider still gets their fixed fee for the visit. But now that landscape is starting to change. The CMS quality payment program is starting to adjust fees of providers so that providers with good outcomes get a slightly increased fee while providers with poor outcomes get a slightly decreased fee.

It all comes down to good documentation. Providers need to document appropriately to support the codes they are submitting. Billing a specified, higher severity code but not documenting to that severity (or not documenting at all) can have a huge financial impact. CMS estimates that every year there are hundreds of millions of dollars of over payments to Medicare Advantage plans based on diagnoses that were inappropriately submitted. Through programs like the RADV (Risk Adjustment Data Validation) audits, CMS is looking at potentially huge recoupments from the Advantage plans.

The less money the insurance plans have, the less money they’ll have to reimburse providers. While there may not be an immediate punitive impact on the provider there will be a definite trickledown effect. The Advantage Plans are also beginning to conduct their own “validation” audits on providers and group practices in effort to prevent any recoupments from the RADV audits.

This means that risk adjustment coders are not only needed on the insurance level and the federal level but also on the provider level as well. Medical coders will need to know if the documentation is going to support the requirements and guidelines of external audits. Risk adjustment coders are also needed to validate diagnoses as they pertain to the quality payment programs for CMS.

Audits and adjustments are continuing to rise. Risk adjustment coders who can navigate these complicated policies and master the ICD-10-CM guidelines are in high demand. If you’re interested in obtaining your CRC credential and working in risk adjustment check out the Risk Adjustment Online Course we have available. It utilizes the AAPC curriculum for training medical coders but with the addition of some vital supplemental information, great animations, fun extras, and fantastic resources.

Can Medical Coding Be Self-Taught?

I’m a firm believer that you can learn just about anything watching YouTube tutorials. There are lots of amazing, inspirational stories of people building houses, businesses, machinery, and more that were self-taught by watching YouTube tutorials. With the rising cost of education, countless people are looking into such alternatives to learn skills that don’t require formal education. Many people interested in medical coding are curious if they can self-teach these concepts.

Is it possible? Yes. Is it easy? Absolutely not.

Self-taught medical coding is easier for those already working in the health care field that has a good basis of medical terminology and other insurance concepts. It would be extremely difficult for someone who has absolutely no background in healthcare or any exposure to medical coding. While all the three coding books utilized (ICD-10, HCPCS, and CPT) come with instructions, it’s harder to understand how to utilize them from scratch.

Learning medical coding completely for free simply cannot happen because the books need to be purchased, studied, and are mandatory for testing purposes. But, if you’re determined to do self-study, here are the most budget-friendly suggestions I can offer.

These are the books needed for professional medical coding, which is coding for physician and other medical provider services.

CPT is Current Procedural Terminology. This book is for coding for procedures and is required for the CPC (Certified Professional Coder) exam. The CPC exam dictates that you must have the AMA version of CPT books only. I would recommend getting the edition for the year that you will be taking your examination in.

ICD-10-CM is for diagnosis-based coding for professional services.  For the CPC exam, you can use any version of ICD-10-CM that you want. Make sure you have the CM edition, and not PCS. PCS is only utilized for hospital/facility coding, and not required for the CPC exam. Here is a suggestion of one you can purchase easily online through Amazon. You can check out some of the reviews for more information as well.

HCPCs are codes for durable medical equipment, medications, insurance-specific codes for procedures, and other services. You can have any edition of HCPCS book that you want for you or exam.  You can buy the one above off Amazon easily. If you’re an Amazon Prime member they will even ship it to you for free.

Step-By-Step Medical Coding is an instructional guide that is utilized very commonly in medical coding classes in colleges and technical schools. While you won’t be able to access the teacher’s information (such as test answers) there are select case answers and rationale in the back of the student guide. I would suggest purchasing this book as well as the coding books indicated above. Current year coding books are required when you are testing for any certification exams through AHIMA or AAPC.  You can write, draw, highlight or tab the books in just about any fashion you want. You cannot staple, paste, tape, or add additional pages into the book or white-out entire pages of the book for notes.

Check us out on YouTube for some great tutorials and information on medical coding. There is also chapter-specific information that you can find through your YouTube searches. This will help you in understanding the concepts that will guide you to becoming a medical coder. When you’re ready, purchase some of the practice exams through the AAPC to get some simulation of what the certification exam will be like.

While you can’t become a certified coder for free, there are ways to cut down the cost if you are interested in self-study. Power the tools above and try to stay as focused as possible. Make an agenda for yourself and stick to it. Good luck!

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7 Common Obstacles in Medical Coding

Every job has obstacles — even medical coding. In an industry that changes as often as healthcare, the obstacles often change as well. However, some of those hurdles can be universal for all medical coders. Let’s explore some of the common obstacles in the medical coding field, and what you can do to overcome them.

High Expectations

There’s a lot of hype around medical coding. While it IS a booming career with lots of great benefits (such as working from home), the over-hype can lead to a lot of disappointed newly certified coders. Some educational institutions will make a medical coding career seem as easy as taking a few classes and passing an exam. New coders become filled with dreams of immediately being hired on to work in your jammies at home. There are some institutions that will go as far as to bait moms with claims that they can do medical coding from home while watching young children.

What results are throngs of new medical coders that don’t understand what their “apprentice” status means and are frustrated that they can’t find a work from home job. Institutions are leaving out the concept that although there is a huge need for medical coders, the need is primarily for experienced medical coders. Entry-level positions are hard to come by, and unfortunately, a lot of companies aren’t structuring their staff and workloads properly to allow for entry-level coding positions. There’s also an unfortunate prevalence of “we don’t have time to train new coders” mentalities in the industry.

Learn the stories of how other coders got their first start in medical coding. Understanding how they got started and what to expect can help bring some clarity for frustrated coders.

Not Knowing Guidelines

It can be very shocking when you’re coding a specialty service for months, or maybe even years, and suddenly something in the guidelines catches your eye.

Does that say what I think it does?

Has that ALWAYS been there?


The best thing you can do Is talk to your manager and discuss your discovery and determine next steps. They will know the best way to correct the error going forward and if they have the capacity to review and adjust potential prior mistakes.

Productivity Requirements

The industry has common standards for productivity for medical coding. The benchmarks change depending on the type of coding (professional, outpatient, inpatient, risk adjustment, etc). Meeting those standards is a surprising challenge! Lots of things can factor into lower productivity such as office distractions, poor physician documentation, EMR challenges, or time researching new or complicated coding guidelines. If you’re having problems reaching your productivity, you may need to analyze your day and see what’s taking the most time. There’s no way to quantify what you’re doing without going through the task of timing out all the phone calls, emails, and research.

Not Finding a Job

Finding your first job in any industry is a challenge, and medical coding is no exception. If you’re looking for your first job (or even just a new job) check out my blog 7 Tips to Finding a Medical Coding Job. Learn how to target your efforts and provide quality over quantity when it comes to your job search!

Failed Audits

There’s no bigger ego-crusher to a coder than failing your personal internal audit. Coders are held to very high accuracy levels (usually 95-99%) and we pride ourselves in our attention to detail and accuracy. No one wants to bill a service incorrectly. If you don’t meet the required accuracy of an audit, just take it as a learning opportunity. It’s a time to recognize where you may have a weak area, address it, learn from it, and look forward to your future success. Never let an audit defeat you.

No Remote Jobs

No commute, no stuffy work clothes, no annoying co-workers and funky smells from the lunchroom! It sounds like a dream to work from home but finding permanent remote coding positions can be a struggle, especially for apprentice coders. When it comes to remote jobs, knowing the right people and having the right resume is key. Check out 7 Tips to Finding a Medical Coding Job to find some ideas on where to find them, and look to companies like Project Resume to make your resume stand out for those highly-desired remote positions.

Navigating Insurance Policies

It seems so straightforward in class, but out in the real-world insurance policies don’t always line up with coding policies. Insurance contracts are binding legal agreements, and healthcare institutions must follow the guidance provided in the contract when billing for those insurances. Learning which insurances want things coding certain ways can be daunting. The best way to combat this is to ask for any cheat sheets your organization may have. If they don’t have any, start developing them yourself and update when you get any new feedback on denials and trends!

There will always be obstacles in medical coding. New guidelines, new policies, and learning new specialties are just the tip of the iceberg. The first two years as a coder is a HUGE learning curve. Take each new experience, change, and restructuring as an opportunity to show how adaptable and eager to learn you are. But don’t be afraid to voice your opinions and concerns as needed.

Code on!