What Is a Coding Review Before Invoicing Called?

A coding review before invoicing plays an important role in the financial operations of many organizations, particularly within the healthcare sector. This process helps ensure that services rendered are accurately documented, coded, and prepared for billing. It serves as a quality control measure, preventing financial inaccuracies and maintaining compliance with various regulatory requirements. Integrated into the broader revenue cycle, it aims to streamline operations and facilitate proper financial transactions.

Naming the Process

The process of reviewing coding before invoicing goes by several names, reflecting its specific focus or the industry in which it is applied. One common term, particularly in healthcare, is “pre-bill audit,” which signifies a review of medical codes and documentation prior to claim submission. Another related term is “revenue integrity review,” which focuses on preventing revenue leakage and ensuring financial accuracy across the continuum of patient care.

Other designations include “coding compliance review” or simply “coding audit,” emphasizing adherence to established guidelines and regulations. In a broader business context, outside of healthcare, this pre-invoicing check might be called a “GL coding review,” an “accounts payable invoice review,” or “invoice approval and coding verification.” These terms generally refer to assigning proper general ledger (GL) codes and other accounting details to transactions before they are formally recorded or billed. The specific terminology used often depends on the type of organization and the nature of the services or goods being invoiced.

Components of the Review

A coding review before invoicing involves a detailed examination of various elements to confirm accuracy and completeness. This includes verifying the precision of medical codes, such as ICD-10-CM for diagnoses, CPT for procedures, and HCPCS codes for supplies and services. The review assesses whether the patient’s medical documentation sufficiently supports the assigned codes, ensuring alignment between the services provided, documented, and coded.

Compliance with payer-specific rules and guidelines is another important component. This includes checking for the correct application of modifiers, which provide additional information about a service or procedure. Reviewers also evaluate medical necessity, confirming that services rendered are appropriate for the patient’s condition. Additionally, the review ensures adherence to National Correct Coding Initiative (NCCI) edits, which prevent inappropriate coding of bundled services.

Objectives of the Review

The primary purpose of conducting a coding review before invoicing is to ensure billing accuracy and prevent errors that could lead to financial losses or compliance issues. This proactive approach helps in maintaining adherence to various regulations, such as the Health Insurance Portability and Accountability Act (HIPAA) and guidelines set by the Centers for Medicare & Medicaid Services (CMS). Another objective is to optimize legitimate revenue capture and prevent under-coding, which can lead to lost income for services already provided. Simultaneously, these reviews guard against over-coding, which could trigger audits and financial penalties. Minimizing claim denials and rejections is a significant goal, as a substantial portion of claims are denied due to coding inaccuracies, resulting in delayed or lost revenue.

Personnel Involved

Various professionals contribute their expertise to the coding review process before invoicing.

• Certified Medical Coders (CMCs) possess specialized knowledge in medical classifications, terminology, and billing regulations. They assign standardized alphanumeric codes to medical diagnoses, procedures, and services, forming the language for billing and reimbursement.
• Medical billing and coding auditors conduct in-depth reviews of records and coded data. They identify discrepancies and ensure adherence to coding guidelines and payer policies.
• Revenue Cycle Specialists or Managers oversee the broader financial processes, including these reviews, to optimize revenue capture and manage cash flow.
• Compliance Officers also play a role, focusing on ensuring that all billing practices align with federal and state regulations, minimizing legal and financial risks.

Ensuring Accurate Invoicing

A successfully completed coding review directly contributes to the generation of clean claims, which are accurate and complete, making them ready for immediate submission to payers. This proactive validation significantly reduces the likelihood of claim rejections and denials, which otherwise can lead to substantial administrative burdens and delayed payments.

The expedited processing of clean claims translates into faster reimbursement cycles and improved cash flow for the organization. This financial efficiency supports operational stability and overall financial health. Furthermore, the consistent application of accurate coding and billing practices through these reviews ensures ongoing regulatory compliance, safeguarding the organization against potential audits and penalties from government entities like Medicare and Medicaid. The validated information from the review forms the basis for the final invoice, ensuring that it precisely reflects the services provided and complies with all relevant billing standards before it is sent out.