COMMON PROBLEMS IN MEDICAL CODING

COMMON ISSUES

NOT CODING THE HIGHEST LEVEL

The coder’s job is to code to the highest level of specificity. This means abstracting the most information out of the medical reports from the provider and taking accurate notes. It also means knowing the medical terminology for both procedures and diagnoses. Coding to a general level, or undercoding (which we’ll discuss in a moment) can lead to a rejected or denied claim.

BAD DOCUMENTATION/MISSING DOCUMENTATION

Of course, not coding to the highest level isn’t always the coder’s fault. In certain cases, the provider won’t give the coder enough information about the procedure they’ve performed. Providers may leave important details of the procedure out of the report, or they may provide illegible medical reports. This problem is exacerbated by the next trouble spot on the list.

NOT HAVING ACCESS TO THE PROVIDER

Ideally, every coder would be in constant contact with the provider they’re coding for. Unfortunately, that’s not always the case. Providers aren’t always available to consult on difficult-to-understand claims. Coders have to do the best with what they have in these situations, but you should still try and clarify the report as best as you can.

FAILING TO USE CURRENT/UPDATED CODE SETS

The organizations that maintain the three principal medical coding code sets (the WHO for ICD, the AMA for CPT, and the CMS for HCPCS) update these manuals yearly. It’s up to coders to learn any new or reorganized codes as they come out, and use them correctly. This is partly why professional organizations like the AAPCand AHIMA require every member to complete a certain amount of educational credits every two years. Keeping your skills sharp is imperative.

UNDER AND OVERCODING

We mentioned these in Course 3-7, but they’re worth mentioning again. Undercoding is the purposeful reportage of less expensive medical services than were performed, while overcoding is the reportage of more expensive procedures than were performed. Both of these are fraudulent, and can lead to audits and investigations. These aren’t errors, per se, but we’re obligated to mention them here as something you absolutely must avoid.

UNBUNDLING

Like under- and overcoding, unbundling is not so much of an error as it is a fraudulent practice. Unbundling is closely related to upcoding, in that it involves false reporting designed to earn the provider a higher payout from a payer. Unbundling means separately coding procedures that would normally be included in one umbrella code.