The Coding Tip Corner - August

Common (Yet Costly) Coding Errors

Cerebrovascular Accident (CVA)
As stated in the ICD-10-CM coding guidelines, a CVA is coded as such only until hospital discharge, regardless of discharge destination. A CVA should not be coded:

• As a follow up in the office setting
• As a chronic condition (i.e., annually)
  
  

The sequalae should be captured (I69.3x – I69.3XX) following discharge and at least annually if it persists.

Myocardial Infarction (MI)
Coding an MI that has occurred outside the 28-day timeframe as a new MI is incorrect per the ICD-10-CM coding guidelines. The guidelines state the MI must occur 28 days from onset, not a month or 30 days. Onset date must be documented!

If the patient is still receiving care for the MI after 28 days, then per the ICD-10-CM guidelines, the appropriate aftercare ICD-10-CM code should be used.

Tips to Avoid Common Documentation Issues

Issue: Use of a short list within the electronic health record (EHR).
Often the short list has an incomplete or inaccurate listing of “commonly” used diagnosis codes.

Ways to mitigate this issue:

• These “short” lists should be reviewed and/or updated with the most appropriate, accurate diagnosis codes.
• Additional provider training should be provided to ensure the provider will search for the most appropriate code when it is not found in their short list or medical history.

Issue: Copying and Pasting
Copying and pasting the components of a chart note make the record difficult to determine what truly occurred or what conditions are being actively managed.

Ways to mitigate this issue:

• Make sure that the exam is always current and not copied from the prior visit.
• Ensure that the assessment and plan is always current and relevant to the encounter/visit.
  
  

Issue: Upcoding
This is a common issue where a provider documents a more serious condition than the patient currently presents. It causes inaccurate payments to Medicare Advantage Organizations (MAO) when the providers claims are submitted to the Centers of Medicare and Medicaid (CMS).

Ways to mitigate this issue:

• Ensure providers are properly trained on proper diagnosis code assignment.
• Routinely audit the provider to ensure the diagnosis codes billed are correct. If incorrect codes were documented, a corrected claim can be submitted to the plan.
  
  

Issue: Coding acute conditions as chronic
This is a common coding issue where the provider still documents a condition as acute when the documentation in the assessment and plan supports a chronic condition. This is also common where the diagnosis code is mainly supported in a hospital setting and rarely in a professional setting, i.e., Acute Respiratory Failure, CVA, etc.

Ways to mitigate this issue:

• Ensure providers are properly trained on proper diagnosis code assignment.
• Routinely audit the provider to ensure the diagnosis codes billed are correct. If incorrect codes were documented, a corrected claim can be submitted to the plan.
  
  

Issue: Inaccurate coding
This commonly occurs when the provider uses a deleted or incorrect Current Procedural Terminology (CPT) code. It also affects improper modifier usage, i.e., Bilateral Modifier Application, Correct Coding Initiative (CCI) bundling issues, Modifier 59 Application, etc.

Ways to mitigate this issue:

• Ensure providers are educated on the new procedure codes and modifiers that affect their practice.
• Ensure the (EHR) is updated with the correct CPT codes at least on a yearly basis up to a quarterly basis.
• Ensure the billing/coding staff understand proper modifier assignment.
  
  

Important Reminders
Each encounter must have the enough “MEAT” (Monitor, Evaluate, Assess, and Treat) to support the proper diagnosis code assignment.
Most importantly: If it is not documented, the service, condition, etc., never happened and it does not exist!

AUDITS from a Medicare Advantage Perspective
Audits are used to:

• Determine outliers
• Protect against fraudulent claims and billing activity
• Reveal whether there is variation from national averages
• Identify and correct problem areas before insurance or government payers challenge inappropriate coding

Risk Adjustment Audits chart reviews and audits of medical records to detect missing diagnosis codes and inaccurate diagnosis codes.

• Missing or inaccurate diagnosis codes affect the member’s Risk Adjustment Factor Score, which communicates to the health plan how sick or healthy the member is.
• Audits are mandatory. CMS (Centers for Medicare & Medicaid Services) and OIG (Office of Inspector General) determine:
  • Who will be audited
  • What be audited
  • When the audit takes place
    
    

The insurance plan is required to comply.

Medical Records Requests
As the requests come in, we as the insurer make every effort to request the minimum necessary to complete the request, however, we ask that provider offices realize we have not set the timeframe for completion, but the requesting entity has.

Therefore, we ask that you comply with the request for the medical record and respond in a time-sensitive manner.

If you find the member is at a different location or has left the practice, please promptly notify HTA so that we can move forward with the request as required.
Just as a friendly reminder, this is a contractual obligation between the practice and HTA as well as between the member and HTA.

Examples of what can influence the outcome of a Risk Adjustment Audit:

• Health record does not have a legible signature with credentials or is not authenticated and electronically signed.
• Highest degree of specificity was not assigned to diagnosis.
• A discrepancy exists between billed diagnosis and actual description of the condition noted in documentation.
• Documentation does not indicate a condition as being Monitored, Evaluated, Assessed or Treated (MEAT).
• Chronic conditions and status codes are not documented on an annual basis.