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Many hospitals experience difficulties with Medicare reimbursements tied to payments strictly related to a diagnosis related group (DRG) in which a patient's stay is grouped or assigned. Potentially compounding these difficulties, many large third-party payers have also adopted the DRG system. A lack of knowledge of the intricacies of the DRG system on the part of physicians, administrators, or medical records managers often can lead to hospitals receiving considerably less reimbursement than they are entitled. A computerized coding system that incorporates an expert system can substantially increase reimbursements by simplifying the coding process, identifying overlooked diagnoses, and identifying any missing procedures.

As outpatient volumes increase in hospitals across the country, more and more coding responsibilities are being placed with the patient accounts department. Both registration and outpatient billers are involved in assigning current procedural terminology (CPT) codes for surgery and emergency room procedures, as well as maintaining the hospital's chargemaster. Often these responsibilities are assigned without regard for the level of coding expertise and degree of clinical knowledge of the personnel involved, which can lead to significant loss of reimbursement and untimely billing delays. This article addresses common problems and offers suggestions for improving coding, minimizing problems, and increasing billing efficiency.

With the implementation of the revised CPT4 coding structure on March 31, 1992, physicians and healthcare financial managers alike were reminded of the fact that more regulation often means less reimbursement. Authors Ciotti and Smith offer a personal look at how they struggled with the revised regulations and a guide to this "coding labyrinth."