what can a coder use to ensure correct coding?

Medical coding errors fall into the broad categories of "fraud" and "abuse."

Medical practices are concentrating on critical exercise changes in 2020 and 2021, but it is important not to lose focus on the basics of right coding. Don't be guilty of common CPT and ICD-10-CM coding errors, equally it tin not but cost your practice millions of dollars in lost revenue, but cause compliance problems that could tag your do for an audit. Hither are some mutual errors that can lead to practice headaches and loss of revenue downward the road.

1. Randomly using modifiers. Modifiers are the two-digit codes added to a service or procedure that tells the payor of special circumstances. The American Medical Association (AMA) develops CPT modifiers, which are numeric, and the Centers for Medicare & Medicaid Services (CMS) develops HCPCS modifiers, which are alphanumeric or alphabetic. Both types of modifiers can be used on CPT or HCPCS codes. Why would someone randomly apply a modifier? Misunderstanding, incorrect information, or a want to get a claim paid, just to mention a few examples. But for both compliance and revenue reasons, correct utilize of modifiers is critical. Using modifiers requires an understanding of the global surgical package and National Correct Coding Initiative (NCCI) edits. There are several skillful coding books on the market that exhaustively explain modifiers.
2. Selecting the incorrect procedure code. With more than than 75,000 CPT codes, information technology is easy to select an incorrect procedure code. Withal, the source of such an error is unremarkably not defoliation nearly the procedure performed. Incomplete or inaccurate code descriptions on encounter forms, crook sheets, and electronic accuse systems are significant sources of error. Failing to read the editorial comments at the start of the section in the CPT volume or the notes near the code is some other cause of this blazon of error, as is not reading specific coding companions available to aid in special circumstances.
3. Failing to link diagnosis codes. A CPT or HCPCS lawmaking tells the payor what service was performed. The diagnosis code tells the payor the reason for the service. Some patients present for more than one condition may require unrelated services. Other patients may receive a service that is only covered for a specific indication. For instance, say a patient presents to a family physician for hypertension, but has a wart destroyed during the same visit. The code for the office visit must exist linked to hypertension, and the code for the wart destruction must be linked to the diagnosis lawmaking for warts. About often, merely one diagnosis is listed or linked, and denials are then a given.
4. Using a nurse visit in place of another service. Some practices withal believe that they can charge a nurse visit with an injection or for a venipuncture "because our nurse takes the patient'due south vital signs." Or they ask, "can we bill a nurse visit with a flu shot?" Nurse visits are arranged into injection codes, and will not be paid separately by a payor using NCCI edits, or any payor using proprietary edits. Equally for the venipuncture, the practise motivation is that a nurse visit pays more than than a venipuncture. Merely information technology does non accurately describe the reason for the visit, or the service performed. If the reason for the visit and the service performed was venipuncture, beak venipuncture. If the patient presented for an allergy shot, bill for the administration of the allergen. Assessing the patient pre- and post-shot is function of the payment for the administration of the planned injection.
5. Not keeping up to appointment. Medical practices and hospitals are understandably cautious most budgets. But declining to keep upward to date on new coding rules and initiatives is an expensive mistake. It results in lost revenue and potential compliance risk for practices. I see many practices pouring hundreds of thousands of dollars into electronic medical records (EMRs) and new medical diagnostics, merely when I ask what their coding education budget is for the twelvemonth, rarely do I hear more than $1,000 – and that's a practise that's ahead of the curve. Equally a healthcare consultant, I find myself in more practices with coders using dated code books, referencing outdated material, and not having the financial resources to bring their staff up to speed on the current rules.

When it comes to medical coding errors, they fall into the broad categories of "fraud" and "corruption."

The onetime involves intentional misrepresentation. The latter means "the falsification was an innocent mistake, but nonetheless representative," according to the AMA'southward Principles of CPT® Coding, 9th edition. An example of corruption could involve coding "for a more complex service than was performed due to a misunderstanding of the coding system," the text notes.

The AMA has a number of resource to assistance yous accurately bill procedures and services with Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding Arrangement (HCPCS) codes.

Hither are some of the most common mix-ups to avert in medical coding.

Unbundling codes. When there is a unmarried lawmaking bachelor that captures payment for the component parts of a procedure, that is what should be used. "Unbundling" refers to using multiple CPT codes for those parts of the process, either due to misunderstanding or in an effort to increase payment.

Upcoding. Say a physician meets for a few minutes with a patient almost a routine question, only the coder bills for a full exam lasting 45 minutes, because that what was checked on the charge capture form. That is a no-no, though oftentimes, cases of upcoding are not so blatant.

Only sometimes they are, and the consequences tin can be severe. I psychiatrist was fined $400,000 and permanently excluded from taking part in Medicare and Medicaid, in part due to upcoding. He billed for 30- or lx-minute contiguous sessions with patients, when in reality, he was simply meeting with patients for 15 minutes each to do medication checks.

Failing to check NCCI edits when reporting multiple codes. CMS developed the NCCI to help ensure that correct coding methods were followed, helping providers avert inappropriate payments for Medicare Part B claims. These are automated prepayment edits that are "reached by analyzing every pair of codes billed for the same patient on the aforementioned service engagement by the same provider to encounter if an edit exists in the NCCI," the AMA's text notes. "If at that place is an NCCI edit, one of the codes is denied."

Case: say you bill for a lesion excision and pare repair on a single service date. But CPT coding guidelines say unproblematic repairs are included in the excision codes, and so separately coding the repair would be wrong and generate an NCCI edit. Just if the repair was performed on a different site from where the lesion was removed, it is OK to beak for both and append a modifier to allow the payor know that the procedure was indeed separate from the excision.

Improper reporting of the infusion and hydration codes, which are time-based. Good documentation of the commencement and stop times are essential for medical coders to properly pecker for these services. And then at that place are wrinkles involving services that are provided over two days of service.

Example: A continuous intravenous hydration is given from 11 p.k. to 2 a.chiliad. In that case, 96360 would exist reported once and 96361 twice. For continuous services that concluding beyond midnight, use the date in which the service began and report the total units of time provided continuously, per CPT. However, if .instead of continuous infusion, a medication was given by Four push at 10pm and 2am, this is not considered continuous, and ii administrations would be reported every bit 96374 initial and 96376 sequential.

Improper reporting of injection codes. Only written report 1 code for an entire session during which the injections take place, instead of multiple units of a lawmaking. This error in coding has been a peak 10 Recovery Audit Contractor (RAC) inspect recoupment in the past few years.

Reporting unlisted codes without documentation. If you must use an unlisted code to properly nib for a service, you must properly document it.

Sometimes, it's just about the coin.

Choosing the correct lawmaking can make a difference of $50.

When you are attempting to distinguish nasopharyngoscopy from laryngoscopy, merely retrieve this: what matters almost is the area the ENT examines, not where the physician inserts the telescopic.

When choosing between nasopharyngoscopy (92511, Nasopharyngoscopy with endoscope [separate procedure]) and laryngoscopy (31575, Laryngoscopy, flexible fiberoptic; diagnostic), you should consider not whether the ENT introduces the scope through the oral fissure or the nose, as you lot might call up. Instead, the key to proper coding is the anatomic area (nasopharynx or larynx) the ENT examines with the scope.

Sometimes, physicians cull to perform a nasal scope insertion for a laryngoscopy, considering inserting the scope through the patient's nose is easier than making the patient concord his mouth open for a long time, and because going through the nose doesn't provoke the patient'south gag reflex. Then if you read "nasal scope insertion" in your doc's documentation and assume he or she performed a nasopharyngoscopy, y'all could exist jumping to an incorrect conclusion.

Remember that 92511 reimburses higher than 31575 in the non-facility setting (3.32 relative value units vs. 1.91 RVUs, or about a $50 difference, on average), and so choosing the correct code has significant meaning for your bottom line.

Solution: read your ENT's documentation very thoroughly to discern what anatomic function he or she examined with the telescopic procedure; this fact should guide your code selection.

Example: if the documentation states that the physician performed a nasal scope insertion and examined the interior of the patient'south larynx (this provides a better view of the upper airway than a traditional mirror exam), you lot would written report 31575.

If, nonetheless, the doctor examines the nasopharynx (that is, the eustachian tubes, adenoids and choanae, or the area where the throat and the nasal passages meet at the cease of the hard palate), the correct code is 92511, regardless of where the ENT introduces the telescopic.

One last example: K91.71, Accidental intraoperative laceration of digestive system organ during a procedure on the digestive system.

Coders are often over-coding/reporting when a doc documents that the laceration was expected/incidental/anticipated during hard lysis of adhesions.

Coders are non always reporting or querying Dr. for intraoperative lacerations due to clinical documentation improvement (CDI) or other directives at a facility when patently significant. At the very least, a query should exist done on any questionable intraoperative lacerations, as to whether they are truly complications, or expected/incidental/anticipated lacerations.

Programming Note:

Heed to Terry Fletcher report this story live today during Talk 10 Tuesdays, 10-x:thirty a.m. EST.

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Source: https://icd10monitor.com/icd-10-cm-and-cpt-coding-mistakes-can-cost-you-and-not-just-financially/

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