Recently I was talking with a colleague about the most common coding errors or variances we’ve been seeing lately when conducting inpatient coding audits. The selection of the “Principal Diagnosis” and a “Missed or Unsupported Secondary Diagnosis” certainly were at the top of the list. But there are some other areas that we as HIM Coding professionals should also be aware of and learn from. The following are three other very specific clinical coding mistakes that have also been identified on audits.

  1. assigning organism (B codes) as principal diagnosis instead of the infection
  2. assigning a symptom code (R codes) as principal diagnosis instead of the confirmed diagnosis
  3. assigning unspecified codes when a higher level of specificity is documented (i.e., unspecified hypotension instead of hypotension of hemodialysis, unspecified miliary tuberculosis instead of tuberculosis of lung, etc.)

Review the Official Guidelines for Coding and Reporting will help to learn and better understand the guidance relating to the above audit findings:

Chapter 1 b. Infectious agents as the cause of diseases classified to other chapters Certain infections are classified in chapters other than Chapter 1 and no organism is identified as part of the infection code. In these instances, it is necessary to use an additional code from Chapter 1 to identify the organism. A code from category B95, Streptococcus, Staphylococcus, and Enterococcus as the cause of diseases classified to other chapters, B96, Other bacterial agents as the cause of diseases classified to other chapters, or B97, Viral agents as the cause of diseases classified to other chapters, is to be used as an additional code to identify the organism. An instructional note will be found at the infection code advising that an additional organism code is required

General Guideline 4. Signs and symptoms. Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a related definitive diagnosis has not been established (confirmed) by the provider. Chapter 18 of ICD-10-CM, Symptoms, Signs, and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified (codes R00.0 – R99) contains many, but not all, codes for symptoms. See Section I.B.18 Use of Signs/Symptom/Unspecified Codes

General Guideline 9. b. “Unspecified” codes.  Codes titled “unspecified” are for use when the information in the medical record is insufficient to assign a more specific code. For those categories for which an unspecified code is not provided, the “other specified” code may represent both other and unspecified. See Section I.B.18 Use of Signs/Symptom/Unspecified Codes

Certainly, mistakes can happen but a best practice is to learn from them. Anytime an audit is conducted, it’s an imperative that the findings be provided and discussed with the coding staff.  Include the use of the Official Guidelines for Coding and Reporting as well as AHA Coding Clinic for explaining the appropriate coding selection or deletion.

When we receive a “claim” denial, an audit or validation of the clinical codes should be conducted. Having an HIM Coding professional on your “Denials/Appeals” committee is essential and brings great value to the process. Sometimes there is the perception that the claim was denied due to coding errors, however, a review must be performed in order to confirm where the claim issue lies.

Across healthcare we usually see a coding accuracy target goal of 95% or higher, and this helps to drive accuracy and pride in our work. But, also coding accuracy can improve revenue, improve and/or maintain compliance, provide data integrity, decrease denials, increase staff moral and drive a quality centered workplace.

Take a look at your coding audit results and determine the cause of the coding errors (mistakes) using a process in which the coding staff can and will learn from.  This includes reviewing the guidelines and using AHA Coding Clinic. Also, be sure that your external coding vendor or consulting firm has a well-rounded and thorough process for sharing and learning from the coding audits they perform. No time like the present to learn and grow from our mistakes!

Written by Gloryanne Bryant, RHIA, CDIP, CCS, CCDS, AHIMA Approved ICD-10-CM/PCS Trainer

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