Coding Blast – June 2024

Keep Electronic Medical Records (EMR) up to date with the latest diagnosis codes

While EMR are intended to allow physicians to keep all information in one place and easily share records between provider offices, this is possible only if providers and staff maintain the EMR on a regular basis. Who has the ownership of updating this in your office?

Connect the chief complaint (or the reason for the visit) to what is being addressed and evaluated

• Who makes sure the medical conditions addressed are also updated in the patients’ medical history?
• Have any medical conditions listed been resolved?
  
  

We understand that most coders need to meet productivity standards, however, it is also extremely important to focus on quality and utilization of the most accurate codes available. Coding accuracy requires continual learning. Codes have the potential to change in October and April of every year. Although it is rare, there have been occasions where a random change happens between those times as well. If you are reviewing a record and something seems missing, question before coding. Specificity is one of the top ways to maintain coding accuracy!

When coding a record, be aware that any record you submit a code for is subject to an audit by several entities. These include CMS, NCQA, and the OIG just to name a few, and unfortunately these requests can go back several years and can carry a large impact on revenue. Auditors verify that medical records reflect the care provided and that coding corresponds to their diagnoses and procedures. They check for completeness, accuracy, coding, and documentation standards’ compliance.

Below are a few coding pitfalls to avoid coding errors, which impact care and revenue:

1. Do you find yourself coding unspecified codes over and over?
2. Are you unable to document the laterality of the condition?
3. Are you coding to the highest level of specificity, without upcoding?
4. Are you undercoding due to unsupported documentation?
5. Are you using the current code sets?
6. Multiple coding should not be used when the classification provides a combination code that clearly identifies all elements documented in the diagnosis, i.e., Type 2 diabetes with severe nonproliferative diabetic retinopathy with macular edema, right eye — correct code is E11.3411, one code only!
7. Are you coding from a note that has simply been copied and pasted?
   
   

Think before you code! Does the information given support the codes you are using? The time to question is before you code, not as an afterthought!

Moving forward, our plan is to bring you the GOOD, the Bad and occasionally the Ugly when we see it in the coding world of our records and to keep you informed of any changes. We are always open to any questions or comments regarding coding. We can be reached at riskadjustment@htanc.com.

Let’s work as a team to strive for the GOLD standard of documentation!