As the landscape of medical coding evolves, accuracy and compliance remain crucial for healthcare organizations. With new CPT 2026 code updates, advancements in digital health, and the growing role of AI, coders face increasing complexity. This guide covers expert tips to boost medical coding accuracy, prevent documentation errors, and keep revenue integrity intact. 1. Stay Informed on CPT 2026 Code Updates Regularly reviewing CPT 2026 updates ensures coders remain compliant

Flat lay of revenue report with a calculator, pencils, and notebook. The pressure on hospital-based coders working in high-acuity areas like emergency departments, observation units, and infusion centers is immense. Every keystroke, every selection within the electronic health record (EHR), directly impacts the facility’s financial health. When documentation falls short, revenue integrity suffers immediately. For those navigating the complexities of EPIC documentation, ensuri

Determine Medical Necessity and Support-IV Access Within This report provides a structured method for determining whether the use of multiple intravenous access sites is supported by documentation within the Epic electronic health record. The intent is to guide coders in evaluating documentation for medical necessity rather than clinical preference. This report is designed for charge capture specialist and compliance review and is not intended to guide patient care decisions.

The High-Stakes Translation from Clinical Care to Understanding Epic's Medication Administration Record (MAR) for Billing and Coding In an integrated Electronic Health Record (EHR) like Epic, clinical documentation actions have direct and immediate financial consequences. At the center of this dynamic is the Epic Medication Administration Record (MAR)—a document that is frequently misunderstood by revenue cycle professionals. Far from being a simple checklist of medications

Why “Given” in Epic Does NOT Automatically Mean Billable Excellent and crucial question. This gets to the very heart of your role as a charge capture specialist. In Epic (and most EHRs), the status "Given" is a clinical documentation point, not a billing trigger. It means the medication was administered to the patient, but it does not mean it meets all the complex rules for professional or facility billing. Here’s a breakdown of why "Given" doesn't equal "Billable," focusing