The article focuses on certain important areas in the medical coding process where medical coders tend to err in spite of being focused on the job.
Accuracy is important in medical coding because physician reimbursement, medical data collection, hospital payments and physician services all depend on the medical codes. However, errors can occur any time – even when the coders are focused on their work, which is usually a result of the mechanical, routine nature of the work. To avoid poor coding habits, there are a few areas coders need to identify and improve. Accurate medical coding can benefit a medical practice in many ways such as improved patient care, on-time reimbursement, reduced hassle of audits and greater efficiency.
Let us look at some of the key areas where medical coding errors are bound to happen.
Improper documentation - Often, documentation by physicians is inadequate or incorrect, and then it will be extremely difficult for coders to ensure accurate coding. Coders have a habit of not going too much into the details of medical records. They simply browse or speed read the documents and code accordingly.
For instance, the main code for pneumonia, SARS associated corona virus is 480.31. But, the coder in real terms may mistake it as viral pneumonia and enter the code 480 for the same, resulting in serious error. Coders should be clear and informed about each and every aspect of the codes entered for any health problem.
In certain cases, coders with an objective to increase their productivity do not give adequate attention to the quality side. Consequently, they may use unofficial resources and spend less time reviewing all documentation. They may solely depend on physician dictation and may ignore the associated notes. This can cause a coder to rush through the codes before systematically reading the documents, thus leading to coding errors. Hence, verifying the medical records and coding system in detail before assigning any specific code is mandatory to avoid the possibility of errors.
Memorizing codes - Experienced coders may happen to memorize several important codes after using them repeatedly. They may enter the codes out of their memory and not refer to any other resources such as medical reference books or journals. At times, their memory power may fail, resulting in coding mistakes.
Creating cheat sheets - Coding cheat sheet is a limited list of ICD-9 codes and their descriptions. This is a good alternative for coders to keep away from researching codes. However, these resources are not constantly updated (with specific details associated with each code) and can become outdated or are not all precise or detailed enough for accurate diagnosis, leading to potential errors.
Incorrect principal diagnosis selection – Lack of comprehensive knowledge about basic coding principles and terminology results in errors. The coding job experience and the in-depth training undergone by coders will determine their job expertise and also help them stay updated about current coding guidelines. Errors may also occur when coders misinterpret a coding guideline. Incorrect principal diagnosis selection includes –
- Applying the coding guidelines wrongly for principal diagnosis (when the coder selects the diagnoses when more than two diagnoses similarly meet the definition of principal diagnosis
- Coding a specific symptom or sign rather than the definitive diagnosis
- Coding a symptom when a complication code needs to be assigned
- Coding from a discharge summary alone
Using clinical encoders – Coders use clinical software programs to follow coding pathways to find out or research on specific codes and DRG (diagnosis-related groups) assignments. Even though software applications may allow them to find codes easily, programs can be defective. Coders may follow incorrect coding pathway, resulting in incorrect code assignment without even the coder realizing that a specific error has happened. Hence, it is highly recommended that coders find codes through the code books even though it is a time consuming process. The end result of inaccurate coding depends mainly on how the codes are used. Instead of relying on any unauthorized websites for the latest medical codes, it is advisable to search for up-to-date codes at the CMS website.