Radiology Coding Alert

Use these tips to keep your coding correct.

While reforms are helping to improve the prior authorization process, the process can still be tedious and frustrating. As a result, some practices may seek prior authorization for upcoming encounters, and code only for what procedures they know will take place — thinking they’ll save time and money. However, inaccurate reporting can result in enforcement actions by federal agencies looking to prevent fraud, waste, and abuse.

Learn why undercoding is just as problematic to your practice as overcoding encounters.

Consider The Circumstances of This Encounter

Picture this: A patient at your practice requires an endovenous ablation of their left leg vein, and you seek and receive prior authorization for the service. While the provider is performing the ablation under image guidance, they realize that the situation requires thrombolysis — for which no one sought prior authorization. If you code this encounter according to the prior authorization, are you undercoding the encounter?

For example, what if you just code the endovenous ablation, but then the provider notices the patient has deep vein thrombosis (DVT) during the endovenous ablation?

Now the patient needs more surgery, more inpatient or other facility stay, but there’s no record for a thrombolysis even though you have recorded images of the DVT, which doesn’t match what was reported by the surgeon or physician. This could lead to a payer inquiry: How did you find out the patient had DVT from an endovenous ablation alone?

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 endovenous ablation even though thrombolysis was performed could fall under that umbrella. The falsification was an innocent mistake but nonetheless representative of medical coding errors that fall into the category of fraud and abuse, 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.

Prioritize Accuracy Above All Else

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.