Medical Coding Inefficiencies and How Tech Can Help

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Clinical coding processes are frustrating. While the process may vary by organization, there are a few things that are common in the process. First, clinicians add codes in the patient note and put that in the EHR. This note gets sent to the coding team, who reviews it to ensure that things are coded properly. Then, if the coding team has questions, they send queries back to the physicians. 

Here is where part of the problem and frustration comes in. The query that the physician has to answer may be about a patient appointment that was days or even weeks ago. Physicians have to try and recall information, especially if they do not have all the details in the chart. And this can be time-consuming: one query can take up to 20 minutes to answer. And physicians see a lot of patients, so there may be a lot of queries. This is frustrating because it takes the physician’s time and focus away from the patients they are working with at that time. 

This is also frustrating for the coding team. If the physician’s note doesn’t have enough information to determine which codes should be used, the coder needs to ask the physician questions. Incomplete documentation may also lead to billed claims being denied, leading to lost reimbursement. However, it may take days or even weeks for the physician to respond, or they may not respond at all. Each unanswered physician query reduces potential reimbursement by an average of $3150. This inefficient process not only makes it hard for the coding team to do their job, but it costs the organization a lot in potential reimbursement. 

In addition to being inefficient, the coding process is impacted by the fragmented documentation paradigm. Coding is based on notes in the EHR, but not everything makes it to the EHR. Because EHRs are not designed for clinical workflows, clinicians jot down information on sticky notes, in text messages, in emails, in word documents, and more.  Then, when clinicians go to write the patient note, they may forget about or misplace these workarounds, meaning that information doesn’t get into the chart. Not only does this mean that the chart is missing patient information, it also means that work that physicians do is not being coded for and reimbursed.   It’s estimated that up to 1% of net charges are lost due to charge leakage. While 1% may not sound like a lot, it can add up quickly in large health systems. 

So, how can we improve the coding process? By integrating it into clinical technology that matches clinical workflows. It should be easy for clinicians to pick the correct codes for every part of their patient note, and it should be available directly in the technology they use to take notes throughout the day. This saves time, reduces frustration for everyone involved, and improves reimbursement.  

Powered by an integration with IMO, CareAlign integrates coding directly into the clinical workflow. When clinicians enter a problem into CareAlign’s iterative patient wiki, codes pop up automatically, allowing clinicians to pick the code for each specific problem. This reduces the back-and-forth queries between clinicians and the coding team, allowing everyone to do their job more efficiently. Additionally, by improving documentation paradigms, CareAlign helps improve the accuracy of reimbursement. 

Want to learn more about how CareAlign implements coding into our workflows? Email us at