September Coding Tip Corner

If you are aware of the following common coding errors and implement office strategies to avoid them, you can improve the accuracy and efficiency of coding, resulting in fewer claim denials and a reduction in compliance risks.

Common coding errors when coding a condition with a complication include incorrectly sequencing the principal diagnosis, failure to link the complication to the appropriate procedure or condition, and not using the most specific codes available. These errors can lead to claim denials, inaccurate risk adjustment, and improper reimbursement.

Here are a just few examples:

• Lack of Specificity: Using unspecified codes when specific codes are available is a common error. An example would be using “unspecified CKD” — a more specific code for the stage of the CKD should be used. This could be done by confirming the stage with the provider or noting lab results, if current.
• Documentation Issues: Incomplete or vague documentation can lead to misinterpretations and incorrect coding. Coders should be able to rely on the medical record to accurately reflect the patients’ condition and the services provided.
• Upcoding and Downcoding: Upcoding (assigning a higher-level code than justified) and downcoding (assigning a lower-level code than justified) are serious errors. Upcoding can lead to fraudulent claims and downcoding can result in lost revenue.
• Failure to Follow Guidelines: Coding guidelines, such as those from the National Correct Coding Initiative (NCCI), must be followed. These guidelines dictate how codes should be used together, and failing to follow them can lead to denials.

As a coder, you should query a physician when the medical record documentation is unclear, such as when you see:

• Missing Information
• Conflicting Documentation
• Incomplete Documentation
• Clinical Indicators without Diagnosis
• Lack of Support for the Diagnoses
• Discrepancies in Procedures and Documentation