Gastroenterology Coding Alert

Get helpful tips on how to avoid accidental coding abuse.

Even the best-intentioned and most experienced coders make mistakes. Undercoding ranks as one of the most common issues that practices face — and can cause both financial and professional woes.

For example: In order to save time and money, some medical practices may opt to only seek prior authorization, and therefore, code for services they know will definitely occur during a patient encounter. You may be inclined to think that this type of inaccurate reporting can save your practice money, but in actuality it can look like fraud, waste, and abuse to federal agencies.

That’s why it’s always best to prioritize accuracy. Here, you’ll find information to help you understand why precise coding matters as well as ways to avoid accidental undercoding.

Consider the Circumstances of This Encounter

Picture this: A patient at your practice requires an endoscopy, and you seek and receive prior authorization for the service. While the provider is performing the endoscopy, they realize that the situation requires a biopsy — for which no one sought prior authorization. If you code this situation according to the prior authorization, are you undercoding the encounter?

Let’s say you did just code the endoscopy, but then the patient’s biopsy comes back positive for cancer.

Now the patient needs more surgery and more inpatient or other facility stay, but there’s no record for a biopsy even though you have a pathology report, which doesn’t match what was reported by the surgeon or physician, says Terry Fletcher, BS, CPC, CCC, CEMC, SCP-CA, ACS-CA, CCS-P, CCS, CMSCS, CMCS, CMC, QMGC, QMCRC, owner of Terry Fletcher Consulting Inc. and consultant, auditor, educator, author, and podcaster at Code Cast, in Laguna Niguel, California. This could lead to a payer wondering how you found out about the cancer from an endoscopy alone and how you got a pathology report.

Know That Undercoding Can Be Fraudulent

The scary f-word in healthcare is fraud, which the Centers for Medicare & Medicaid Services (CMS) defines as “an intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or some other person.”

So, if fraud is the intentional misrepresentation of codes, then coding just an endoscopy — even though a biopsy was performed — could fall under that umbrella. The falsification was an “innocent mistake” yet was still intentional, but nonetheless representative of medical coding errors that fall into the category of fraud and abuse, Fletcher says.

Prioritize Accuracy

As a coder, you know that your efforts do a lot to dictate a patient’s narrative of health and illness; you provide an official record of their condition. Therefore, making sure your code choices reflect the patient’s specific situation is crucial for myriad reasons.

“It’s important to make sure that we code accurately. Downcoding, undercoding, trying to capture it just for money is wrong. You may find yourself in a really compromised situation,” Fletcher warns.

Of course, coders who intentionally undercode may think they’re doing something helpful, either by avoiding expense for a patient or a payer or trying to avoid a mistake made in a prior authorization. “Coding lower to avoid problems is an old school mentality to avoid problems, but CMS has been clear that any inaccurate coding, high or low, is inappropriate,” explains Chelle Johnson, CPMA, CPC, CPCO, CPPM, CEMC, AAPC Fellow, billing/credentialing/ auditing/coding coordinator at County of Stanislaus Health Services Agency in Modesto, California. Additionally, “the medical records are a history of what was addressed and treated during the visit. If the documentation is too vague to code, then most likely there are significant gaps in the documentation that need to be addressed to have an accurate record of what occurred,” Johnson continues.

Bottom line: Make sure your code choices are accurate. “We can’t do things just to get paid, we have to do things correctly,” Fletcher says.