Practice Management Alert

If your practice’s claim acceptance rate isn’t where you’d like to be, you may be playing by rules that don’t actually apply.

Here are three myths that need revisiting and three examples to help you curb coding complacency.

Myth 1: Downcode if You’re Doubtful

This myth needs busting because it is incorrect — and it can also lead to investigations and allegations of fraud. “Coding lower to avoid problems is an old school mentality to avoid problems, but CMS [Centers for Medicare & Medicaid Services] 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.

“The importance of the medical records is more than just accurate coding,” Johnson says. “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.”

Example 1: A provider documents “diabetes without complications.” ICD-10-CM Official Guidelines, Section I.C.4.a.2, tells you that if the provider doesn’t include the type of diabetes, you should default to E11.-. Since the provider noted the diabetes was without complications, that guideline leads you to E11.9 (Type 2 diabetes mellitus without complications). You’ll want to still check with the provider regarding whether it’s type 1 or type 2.

Treatments and costs vary dramatically, potentially having a dramatic impact on the patient’s health and insurance coverage. Education and communication are key to ensuring an accurate claim.

“By having open conversations with our providers in regard to compliance guidelines, appropriate leveling, and documentation, these issues can be eradicated or at the very least drastically reduced,” Johnson says.

Additionally, the term “without complications” implies not only that there are no complications (which is rare) but also that the condition is actively being controlled. Without Z79.4 (Long term (current) use of insulin) or other code to indicate a specific treatment modality, the insurance company could deny the claim.

Coding alert: For E10.- (Type 1 diabetes mellitus), reporting Z79.4 is not required. Type 1 patients are insulin dependent, so insulin use is automatically implied by the code. You’ll notice E10.- is the only diabetes mellitus category without a “Use additional” code for insulin.

Myth 2: Commit Codes to Memory for Peak Efficiency

Coding from memory is likely to cause errors. In any specialty practice, you might see a handful of codes frequently, and you may have even made a cheat sheet with commonly used codes.

However, skimming a record and entering a code from memory or from a cheat sheet is likely to cause problems in the long run. “Experienced coders can definitely make mistakes due to complacency,” says Brooke Hullett, CPC, CRC, CFPC, an independent clinical coding specialist with The Veranda Medical Group in Nashville, Tennessee.

“It is important that we not only stay up to date on current code and policy changes, but also continue to challenge ourselves by creating new goals,” Hullet adds.

Example 2: A patient is diagnosed with hypertension and a heart condition. You see the words “hypertension” and “heart condition” and code as if the two are related. However, guideline I.C.9.a.1 reminds you that “Hypertension with heart conditions classified to I50.- or I51.4- I51.7, I51.89, I51.9, are assigned to a code from category I11, Hypertensive heart disease. Use additional code(s) from category I50, Heart failure, to identify the type(s) of heart failure in those patients with heart failure. The same heart conditions (I50.-, I51.4-I51.7, I51.89, I51.9) with hypertension are coded separately if the provider has documented they are unrelated to the hypertension. Sequence according to the circumstances of the admission/encounter.”

In other words:

• If the documentation does not mention causality but does mention hypertension and a heart condition without heart failure, code using I11.9 (Hypertensive heart disease without heart failure).
• If the documentation states there is no relationship between the two conditions, code I10 (Essential (primary) hypertension), and then report the unrelated heart condition, such as I51.4 (Myocarditis, unspecified).

Myth 3: Providers are the Final Word on E/M Levels

Most providers are not coding experts, which is why it’s so important for coders and auditors to continually educate providers.

“Just because the boss said to do it does not make it correct,” Johnson says. “I work with my coders, billers, and auditors to ensure that not only do they know the appropriate action to take, but why they are taking that action — without the why, the staff is just acting mechanically.”

Example 3: Suppose your provider spent 42 minutes with a patient and tells you the time spent justifies reporting the office visit as 99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using time for code selection, 40-54 minutes of total time is spent on the date of the encounter). However, you disagree.

The patient record states that a patient presents with slight fever, sore throat, and nasal congestion, tests negative for COVID in a rapid test, has a history of seasonal allergies, and is ultimately diagnosed with allergic rhinitis. If the provider spent 40-54 minutes on that encounter, the insurance company is going to wonder why. On paper, the encounter looks simple and low risk, and the diagnosis raises questions about the medical necessity of reporting 99215. The coding may be appropriate from a CPT^® perspective and still be inappropriate and result in denial from a medical necessity perspective as defined by the payer.

Top tip: Taking a few extra seconds to double-check a code or proofread your work is usually enough time to catch a careless error or two. “It is much quicker to double-check your work and send the claim correctly the first time. This keeps everyone paid and happy,” Hullett says.