Can You Ever Know It All?
What is one job that no matter how long you have been doing it, you will never know it all? Coding. No matter how long you have been doing it, you never quit learning! The one thing with coding you can expect is that it will change. Twice a year now, in the Spring (April) and the Fall (October), you can expect change. Over the past few years, we have gone from ICD-9 to what many people feared when ICD-10 came to be, and now we are facing ICD-11 (official date to be announced).
The changes can come in various forms. Codes can be changed by additions, deletions, or revisions. This is part of what requires coding to be a continual learning process. In this article, we will look at three common coding errors often found in audits:
- Specificity: Coding specificity is a shared responsibility between the provider and the coding professional to create a clear clinical picture of the encounter. Providers have an obligation to document conditions to the full extent of their clinical knowledge of the patient’s health. Diagnosis codes should be reported at their highest number of characters available and to the highest level of specificity documented in the medical record at the time of the visit.
- Combining Codes: Combination codes would be those codes which are utilized to represent “the etiology along with the manifestations” or “the diagnosis and the symptoms” within a single code.
- Sequencing: Selecting the most specific codes and putting them in the correct order. This code arrangement is called “sequencing,” and it is an essential step to correct coding.
Specificity
If there are unspecified and specified codes in the same code family, it is always appropriate to code to the highest level of specificity supported by the medical record documentation at the time of the visit. A three-character code is to be used only if it is not further subdivided. A code is invalid if it has not been coded to the full number of characters required for that code, including the 7th character, if applicable.
Example: Type 2 Diabetes with hyperglycemia, stated in the exam and assessment.
Code: E11.65 Type 2 diabetes mellitus with hyperglycemia
Combined Codes
A combination code is a single code used to classify:
A diagnosis with an associated secondary process (manifestation)
A diagnosis with an associated complication
Assign only the combination code when that code fully identifies the diagnostic conditions involved or when the Alphabetic index so directs. Multiple coding should not be used when the classification provides a combination code that clearly identifies all of the elements documented in the diagnosis. When the combination code lacks necessary specificity in describing the manifestation or complication, an additional code should be used as a secondary code.
Example: Assessment & Plan (A&P) Type 2 diabetes with diabetic chronic kidney disease stage 4
Code: E11.22, N18.4
Sequencing Codes
Follow instructions for sequencing, use instructional notes “Code first,” “use additional code,” and “in diseases classified elsewhere” proper sequencing of conditions (ICD – 10 – CM guidelines, I.A.13). Review also Tabular Guidelines.
Example: Assessment dementia with Parkinson's
Code: G20, [F02.80]
To sum it up, coding comes down to knowing the Guidelines, however the Guidelines change, which makes it an ongoing learning experience!
The Risk Adjustment team is open to any questions or suggestions you may have for future articles. Please reach out to riskadjustment@htanc.com.