Common Coding Errors

1. Common Coding Errors Kaye Deaton, MBA, RHIA, CCS, CCS-P COM: 937-257-9793 DSN: 787 kaye.deaton@wpafb.af.mil

3. Typical Causes of Coding Errors Failure to review the entire record Selection of incorrect primary diagnosis Selection of incorrect code(s) Coding diagnoses/procedures not validated by record content Coding only from the index Clinical errors in database or on bill Missed modifiers Clustering Unbundling of procedures

4. Easy to Miss ICD-9-CM Coding Errors Failure to apply 4th or 5th digits Using unspecified codes even though the medical record contains more specific information Using the manifestation code first instead of the etiology code Using disease codes instead of the more appropriate V code

5. Common ICD-9-CM Errors Assigning codes without supporting documentation - Hypertension (malignant) 401.0 - Hypertension (benign) 401.1 - Hypertension (arterial) (essential) (primary) (systemic) (NOS) 401.9 ? Official Guidelines For Coding & Reporting Hypertension 4 Essential Hypertension 4.1

6. Common ICD-9-CM Errors Encounter for Chemotherapy/Radiotherapy When a patient has an encounter solely for the purpose of chemo/radiation therapy, a code from category V58 is assigned as the primary diagnosis. When the patient receives both, both codes can be assigned and either can be assigned as principal. Because the patient is still under treatment for the malignancy even though it may have been removed surgically, an additional code for the malignancy is assigned, rather than a code from the V category. ? Official Guidelines For Coding & Reporting Neoplasms 2.13.A

7. Common ICD-9-CM Errors Do not code diagnoses documented a �probable�, �suspected�, �questionable�,�rule out�, or working diagnosis. ? Official Guidelines for Coding and Reporting Basic Coding Guidelines for Outpatient Services Section H

8. Evaluation & Management Coding Errors Using only one or two codes in a section repeatedly (all office visits coded to two levels) Failing to address documentation requirements for history, exam, and medical decision making for codes that must meet or exceed them (in cases of new patients, initial care, etc) (more of an education issue on how to document) Using time as a determinant, even though counseling and coordination of care did not dominate the encounter Not understanding the definitions of a new and an established patient

9. Common CPT Errors Failure to assign diagnosis(es) codes that support the procedure preformed Failure to use additional ICD-9-CM or CPT codes as indicated by the diagnosis or procedure Double-coding procedures that can be reported with one code (unbundling) ? With the added scrutiny of CPT codes by third-party payers or the Office of the Inspector General to substantiate fraud and abuse of the healthcare (Medicare) system, it is important to minimize errors that can result from incomplete documentation or inappropriate use of codes

10. Dermatology (Lesions) Coding the wrong site Coding the wrong technique (excision vs. destruction vs. paring) Adding together the size of lesions (only applicable to the size of similar wound repairs, not lesions) Choosing malignant or benign lesions incorrectly Codes now reflect the total dimension of the excision, not just the lesion. *Basically, the size of the lesion plus the circumferential margins.�

11. Dermatology (Lesions)(cont.) 11400 � 11446 used to report the surgical excision of benign lesions. Excisions of benign lesions includes the simple closure of the excision site and local anesthesia. 12031 12057 used for intermediate repair 13100-13153 used for complex repair 11600-11646 used to report the surgical excision of malignant lesions. Also includes the simple closure of the excision site and local anesthesia. 12031-12057 used for intermediate repair 13100-13153 used for complex repair

12. Dermatology (Wounds) 12001-12021 These codes are used to report the simple repair of wounds, to include surgically created due to the excision of a lesion. Simple repair is non-layered closure. If multiple wounds are repaired with simple closure and are located on the body in the same anatomical site grouping defined by CPT, the lengths are added together to make one wound closure length when choosing a CPT code.

13. Dermatology (Wounds) Example A: 2.5 cm wound right arm, closed by simple repair 1.5 cm wound left arm, closed by simple repair 4.0 cm wound total, closed by simple repair = 12002 for coding purposes

14. Dermatology (Wounds) Example B: 2.5 cm wound, right arm, closed by simple repair 3.0 cm wound right leg, closed by intermediate repair ? Do not total wounds together for code selection. Even though these wounds are in the same CPT anatomical grouping, the method of closure is different, so each wound is coded individually for coding purposes.

15. Auditory System ? Confusion when documentation states, �myringotomy for insertion of ventilating tubes.� For coding purposes, this relates to a tympanostomy (69433 or 69436) ? Most procedures are considered unilateral. If both unilateral and bilateral, the code descriptor will identify. Removal of impacted cerumen (one or both ears) is used once, without a modifier. Example: 69210

16. Orthpedics 20600-20610 A case study involving arthrocenteses: When a provider reports both the aspiration of fluid from and the injection of medication into the same joint or bursa. These codes include both as indicated by �and/or� in the narrative. Example: If a provider were to aspirate fluid from a patient�s knee and then inject cortisone they should only be reporting code 20610.

17. Digestive System The proper site(s) is not coded�.colonoscopy is coded when only the rectum, sigmoid colon, and a small portion of the descending colon were viewed; for a colonoscopy, the scope must pass beyond the splenic fixture. A biopsy is coded instead of a polyp removal, or both are coded when surgery is performed only at one site. ( If a biopsy is performed and the remaining portion of the polyp is excised, only the polypectomy should be coded. If the polyp is biopsied, but not excised, only the biopsy should be coded. If multiple biopsies are taken without withdrawing the scope,the biopsy should only be coded once.)

18. Digestive System (cont.) Colonoscopies should be coded as to how far the scope was passed, not the level at which the polyp/lesion was removed. Coding both diagnostic and surgical endoscopies at the same time. Hernia Repair Using excision codes when a laparoscope was used Using the terms initial and recurrent interchangeably Failure to use additional codes for mesh/prosthesis for incisional hernia repair

19. Urology Confusion commonly arises between the ureter and the urethra. ? urether � the tube that carries urine from the kidney to the bladder ? urethra � the tube for the discharge or urine extending from the bladder to the outside. 52005 This procedure is over used when reporting cystourethoscopies. It�s often used instead of 52000. The difference is the urethral catheterization. Documentation must clearly identify the catheterization in order to report this procedure.

20. General Medicine 92960 Often used as emergency defibrillation. This is an elective procedure and should not be used to report an emergency defibrillation; service is included in critical care services.

21. HIPAAThat�s One P and Two AA�s What is HIPAA? ? HIPAA is the Health Insurance Portability and Accountability Act of 1996 (21 Aug). Public Law 104-191 which amends IRS code of 1986. ? Centers for Medicare and Medicaid Services (CMS) is responsible for oversight and enforcement of HIPAA transaction and code set standards.

22. HIPAA How did we get HIPAA? Congress mandated the use of standard transactions, coding, and identifiers ICD-9-CM for diagnoses - CPT-4 for most procedures HCPCS for procedures not in CPT CDT-3 for dental - NCD for drugs Electronic signature standards -Standard Taxpayer Identifier 8-digit provider identifier; a 10-digit has subsequently been proposed

23. HIPAA Coding Fraud May Include Submitting services that are not medically necessary Unbundling services Assigning a code for a higher-level of service than the one actual performed Assigning a code for a covered service when the service provided is not covered Assigning diagnoses that were not present Billing for services that were not performed

24. HIPAA Prevention Strategies Properly trained coding staff with ongoing education Comprehensive, up-to-date, internal policies and procedures for coding and billing Internally completed audits to assess coding quality Evaluation of internal coding practices to ensure their consistency with coding rules and guidelines Education of physicians on improving documentation when documentation deficiencies are identified

25. Improving Coding Quality Several steps can be taken to improve the quality of coded information: Develop coding policies � coders need to know what to do about conflicting documentation in the patient�s record Quality improvement studies � when coding discrepancies are found, the cause should be identified and communicated to other coders Measuring coding productivity (quality and quantity) � a quality level of at least 95% or greater is usually established. As far as quantity, organizations vary in productivity standards.

26. Improving Coding Quality (cont.) Consideration in hiring coders � credentialed vs. non-credentialed; years of experience Training Coders � length and extent will depend on the skills and experience of the individuals providing coding services Availability of coding resources - Coding Clinic - Coding Clinic HCPCS - CPT Assistant - Coder�s Desk Reference

27. Thanks for your attention, have a great week, and ENJOY Miami!!!