Medical coding is a vital component of the healthcare industry as it serves as a bridge between providers and payors. Coding involves the translation of medical diagnoses, procedures, equipment and other services into universal alphanumeric codes. Accurate coding is essential for proper billing and ensuring that providers are reimbursed appropriately. This guide aims to help coders understand and avoid common errors in ICD-10 and CPT coding; emphasizing the importance of proper documentation.

1. Incorrect Code Selection

Explanation:

• What are they? Errors in selecting the appropriate ICD-10 or CPT code for a diagnosis or procedure.
• Common errors: Claims rejections, denials, or inaccurate reimbursement.

Examples:

• Selecting a code that describes a diagnosis or procedure that is more severe or less severe than the actual condition.
• Using outdated codes or not updating to the latest version of ICD-10 or CPT codes.
• Selecting a code that was not addressed in the medical encounter. “If it is not documented, it did not happen.”

How to Avoid:

• Continuing education: Stay updated with the latest coding guidelines and annual updates.
• Cross-reference: Use the ICD-10-CM and CPT code books alongside reliable electronic sources such as APC, CMS.gov, AHIMA, AMA
• Coding audits healthcare: “Conduct audits on a monthly to quarterly basis ensuring coding accuracy is maintained at 95% or higher”

2. Upcoding and Downcoding

Explanation:

• What are they? Upcoding is the practice of using a code that provides a higher reimbursement than the actual service provided. Downcoding is the opposite, where a lower level code is used.
• Common errors: Upcoding can lead to legal issues (e.g., fraud, payment recoupment, etc.) and audits; downcoding results in loss of revenue.

Examples:

• Reporting a procedure as more complex than it was (upcoding).
• Reporting a higher level of evaluation and management (E/M) services than provided.
• Using a nonspecific code when a more specific code exists (downcoding).

How to Avoid:

• Accurate documentation: Ensure all services and diagnoses are documented accurately and comprehensively. Query provider if there is contradicting or missing information”. Never assume or infer.
• Coding compliance programs: Implement robust compliance programs to regularly review coding practices.
• Education: Regularly educate coding staff on the importance of compliance and accurate coding in addition to regularly scheduled audit and training for coders

3. Unbundling of Codes

Explanation:

• What are they? Unbundling refers to the practice of using multiple CPT codes for parts of a procedure instead of a single comprehensive code. Be mindful of payor guidelines as well. These override coding guidelines.
• Common errors: When caught, these can lead to claim denials and potential fines.

Examples:

• Separately coding components of a surgical procedure when a single code encompasses the entire procedure.
• Using individual codes for lab tests that should be grouped under a single panel code.

How to Avoid:

• Bundling guidelines: Familiarize yourself with the Correct Coding Initiative (CCI) edits.
• Coding software: Use coding software that alerts you to unbundling errors.

4. Invalid or Missing Modifiers

Explanation:

• What are they? Modifiers provide additional information about the procedure, service, or supply provided without changing the definition of the code.
• Common errors: Incorrect use or omission can lead to claim denials or incorrect reimbursement.

Examples:

• Using modifier -59(distinct procedural service) incorrectly.
• Using modifier -SA when Nurse Practitioner renders service in collaboration with a physician.
• Failing to append modifier -25(significant, separately identifiable E/M service on the same day as a procedure).

How to Avoid:

• Modifier guidelines: Understand and follow guidelines for modifier usage. guidelines. Certain payors (e.g., Medicare) require specific modifiers on certain services rendered.
• Specific training: Provide ongoing training and education on the correct use of modifiers and Suggest adding staying up to date with payor guidelines

5. Insufficient Documentation

Explanation:

• What are they? When the documentation does not support the code that is billed or lack of documentation
• Common errors: Claim denials, audits, and potential legal issues.

Examples:

• Lack of detailed documentation to support higher level E/M codes.
• Missing or incomplete operative reports for surgical procedures.
• Encounters (e.g., visits, procedures, surgeries, etc.) not yet signed by a provider.

How to Avoid:

• Comprehensive documentation: Ensure all aspects of the patient’s visit, diagnosis, and procedures are documented in detail.
• Templates and checklists: Use templates and checklists to ensure all necessary information is captured.
• Code linkage: Supporting Documentation: Ensure there is clear documentation of the services rendered and that it is as detailed as their code selection

Read More: A Comprehensive Guide to Common Medical Coding Errors and How to Avoid Them