I am a Medicare Risk Adjustment Coder. We review medical records for diagnosis codes. Presently, I am performing quality assurance reviews on my co-workers code choices. If I reject their choices, the records go to my supervisor for a 3rd review. When this process is completed, the codes are forwarded to CMS where a Hierarchical Condition Category (HCC) score is established for the patient. The insurance company for which I am employed, is then paid by CMS for the care of our member based on the derived score. The problem I am facing is that, in reviewing the codes, I am often finding that my coworkers are not choosing the correct 4th and 5th digit for the code or are choosing a potentially incorrect diagnosis entirely. It has been suggested that unless these errors effect an HCC, and thereby effect the eventual care score for the member, I should not be marking these as errors, or changing the codes to those that are correct, in an effort to keep the process moving and decrease the number of records to be reviewed by the supervisor. I feel that this is ethically incorrect as it is causing me to accept what I feel is a known incorrect diagnosis code.
Hoping someone might have some input into what they feel about the situation. Thanks so much.
Hoping someone might have some input into what they feel about the situation. Thanks so much.
diagnosis codes, diagnosis coding