Codapedia is now a division of Find-A-Code

Don’t Overlook Diagnosis Codes During Coding Audits

July 14th, 2017 - Betty Stump, MHA, RHIT, CPC, CCS-P, CPMA, CDIP
Categories:   Diagnosis Coding   Audits/Auditing  
0 Votes - Sign in to vote or comment.

Coding auditors focus much of their attention exclusively on C.P.T. codes during the review process. After all, codes reported for E and M visits, surgical procedures, and diagnostic services are what generate revenue to the provider or facility. Even more importantly, errors in reporting these services are frequently what give rise to payer reviews, denials, and investigations for inaccurate billing practices. Reported diagnosis codes on a billing claim are often given only cursory consideration when compared to the documented record. Unless a review is targeted for I.C.D. 10 C.M. accuracy, auditors do not have time or, in rare cases, the clinical expertise to carefully dissect the clinical encounter to compare the documented conditions to the assigned diagnosis codes. Performing professional audits without giving sufficient consideration for the diagnosis codes however, ultimately results in an incomplete audit and denies the client an opportunity to receive valuable feedback and education for documentation improvement. The healthcare industry is shifting and the changes are led by focusing on the delivery of quality care. It is the diagnosis code that identifies and defines the severity of illness and helps drive home the message of medical necessity for rendered services. Increasingly, payers are looking to risk adjustment methods such as the C.M.S. Medicare Advantage Hierarchical Condition Categories, or H.C.C.’s, to determine payment rates. Without accurate clinical documentation and appropriate diagnosis code reporting, the transition to quality will be stymied.

Accurate documentation to support a true picture of patient illness is meaningless if the reported codes are inaccurate, nonspecific, or simply excluded from a claim or reported to the payer. As an example, it is common to find code E 11.9 (Type 2 Diabetes Mellitus without complication) reported for diabetic patients. Review of the documentation however, reveals the patient to have an abnormal foot examination consistent with diabetic peripheral neuropathy and the accurate condition should be reported with I.C.D. 10 C.M. code E 11.42 (Type 2 Diabetes Mellitus with diabetic polyneuropathy). Reporting I.C.D. 10 C.M. codes that are clinically precise and specific but are not supported by the medical record creates a false impression for severity of illness that can easily overstate the patient’s overall health risk. An example of this might be a reported code of F 33.2 (Major depressive disorder, recurrent, moderate) yet the record is documented with nothing more specific than “depression, stable and will continue current dose of Paxil.” The reported code incorrectly overstates the severity of illness (with risk adjustment value) yet the specificity is not supported by the clinical documentation.

Professional auditors should include sufficient time in the review process to validate the accuracy of the clinical record and the reported diagnosis codes as a component of the audit process. Provider education and feedback regarding discrepancies in reported or assigned diagnoses code and the medical record will assist providers in improving their documentation and help ensure accuracy and quality in the clinical record. Be sure to know the Coding Guidelines for diagnosis code reporting and stay current with updates to the I.C.D. 10 C.M. code set. Lastly, as a professional, be certain your clinical skills are up-to-date and that you are prepared with adequate resources to research unfamiliar terms. With over 70,000 codes in the I.C.D. 10 C.M. code set, it is impossible to know all the associated pathophysiology to support their uses but we must know where to look for information that guides us – after all, our job is to be expert in all things coding and auditing!


Questions, comments?

If you have questions or comments about this article please contact us.  Comments that provide additional related information may be added here by our Editors.

Latest articles:  (any category)

Q/A: How Many Diagnosis Codes do I use?
April 15th, 2019 - Wyn Staheli, Director of Research
Question: My patient has a lot of chronic conditions. Do I need to include all these on the claim? I know that I can have up to 12 diagnoses codes on a single claim. What if I need more than that? Answer: More is not always better. You only need to ...
Watch out for People-Related ‘Gotchas’
April 15th, 2019 - Wyn Staheli, Director of Research
In Chapter 3 — Compliance of the ChiroCode DeskBook, we warn about the dangers of disgruntled people (pages 172-173). Even if we think that we are a wonderful healthcare provider and office, there are those individuals who can and will create problems. As frustrating as it may be, there are ...
Q/A: What do I do When a Medicare Patient Refuses to Sign an ABN?
April 8th, 2019 - Wyn Staheli, Director of Research
Question: What do I do when a Medicare patient refuses to sign an ABN? Answer: That depends on whether the patient is still demanding to have/receive the service/supply. If they aren’t demanding the service, then there is no need to force the issue. Just make sure that you still have an ...
Prepayment Review Battle Plan
April 8th, 2019 - Wyn Staheli, Director of Research
Any type of payer review can create some headaches for providers and cause problems for a healthcare office. Even for a practice that has taken administrative steps to try and prevent a prepayment review, it can still happen. A prepayment review means that you must include documentation WITH your claim. ...
Looking Ahead - Changes in Dentistry!
April 3rd, 2019 - Christine Taxin
In the next 10 years, what is the biggest change dentistry will experience? FW: We all know healthcare in the U.S. is changing rapidly. Dentistry is no exception. My opinion is that several big changes are forthcoming. Most often, I think about changes that benefit patients and/or providers. Here are three ...
Q/A: I Submitted a Claim to the VA and it’s Being Denied. Why?
April 1st, 2019 - Wyn Staheli, Director of Research
I submitted a claim to the VA and it’s being denied. Why? There are several reasons why your claim might be denied by the Veterans Administration (VA). However, without more information about the claim itself (e.g., services billed), we can only provide the following general information about the VA and chiropractic ...
Corrections and Updates
April 1st, 2019 - Wyn Staheli, Director of Research
One constant in our industry is change. Policies change, contracts change, and there are updates. Also, people aren’t perfect and mistakes can be made. So this article will cover a variety of topics. Published Articles We appreciate feedback from our valued customers. We have received feedback regarding two of our articles which ...

About Codapedia & Find-A-Code Contact Us Terms of Use Privacy Policy Advertise with Us

Codapedia™/Find-A-Code™ - 62 E 300 North, Spanish Fork, UT 84660 - Phone 801-770-4203 (9-5 Mountain) - Fax (801) 770-4428

Copyright © 2009-2019 Find A Code, LLC - CPT® copyright American Medical Association