Coding accuracy, reimbursement, and ethics

Coding for health status and contact with health services

In the ICD-10-CM, Chapter 21, Factors Influencing Health Status and Contact with Health Services (Z00-Z99), codes are used to describe circumstances or encounters with a healthcare provider when no current illness or injury exists. These codes fall into 16 categories, including contact/exposure, inoculations and vaccinations, health status, history of screening, observation, aftercare, follow-up, donor counseling, encounters for obstetric and reproductive services, newborns and infants, and routine and administrative examinations, plus other encounters that don’t fall into any of those categories. For example, a newborn’s routine checkup with no illness or injury present falls under the newborns and infants / routine examination category (such as Z00, encounter for a routine child health examination) rather than a diagnosis code from another chapter.

Maximizing third-party reimbursement

The most important thing to remember in using the ICD-10-CM is to code the diagnosis to the highest level of specificity - for example, choosing E11.21 (type 2 diabetes mellitus with diabetic nephropathy) over the vaguer E11.9 (type 2 diabetes mellitus without complications) when the record documents a diabetic complication. Obtaining the correct reimbursement is important to the practice’s cash flow, and it depends on proper coding and billing techniques. Here are some other crucial points to remember when submitting diagnostic codes for claims:

• Use the ICD-10-CM manual for the current year, and stay informed of all changes, revisions, and additions published for that year to both the codes and the official coding guidelines.
• Code accurately from documented information, making sure the appropriate code or codes are assigned for all parts of the diagnostic statement, with no additions or omissions.
• Be sure the diagnosis corresponds to the symptoms and treatment. Many codes are specific to age and gender.
• Review data entry to make sure no digits have been transposed.
• Know the insurance carrier’s rules and requirements for completion and submission of claims.
• Remember that incomplete or inaccurate codes may result in delay or denial of reimbursement. An inaccurate diagnosis may have a lifelong negative effect on the patient.

Providers and accurate coding

Detailed documentation in the patient’s health record can help coders code to the highest specificity. Therefore, providers should be trained in how to document patient health records appropriately. Respectfully discuss with providers that diagnostic codes cannot be assigned unless clear documentation is found in the patient’s health record. Some providers may feel that because they care for the same type of cases, specialized diagnostic statements should be implied. However, the medical assistant should stress to providers the importance of detailed documentation and how developing this practice not only improves ICD-10-CM code assignment but may also result in higher health insurance reimbursements.

Staff meetings to review third-party requirements should be held regularly by the medical billing supervisor. Medical assistants should be respectful to the healthcare provider when discussing third-party requirements for more detailed documentation. An understanding and patient attitude toward the healthcare provider goes a long way in building a trusting relationship.

Ethical standards of medical coding

At times coders can feel pressured by decreasing insurance reimbursements and their employers to use fraudulent coding practices. However, if a medical practice is convicted of fraudulent billing, the coders involved may lose their professional certification and face federal penalties. A number of ethical standards have been established for medical coding, and most of these can help coders identify unethical coding behaviors. The following tips explain how to proceed in scenarios that may pose ethical dilemmas:

1. Understand what ethical coding standards mean. Coders face stress from all sides: financial issues, providers, and other coders. However, stress cannot be a compelling reason for coders to intentionally report diagnoses or higher specificity codes without sufficient documentation.
2. Stand your ground. When coding, be true to yourself, even though it can be hard in a stressful environment. When you know a record needs additional documentation to justify reporting certain codes, don’t be afraid to speak up to the provider. Conduct research ahead of time to strengthen your case. For example, search through and print out applicable issues of Coding Clinic from the American Hospital Association website, www.ahacentraloffice.org. The more backup documentation you have, the more likely management will support your ethical coding decision.
3. Say something. Other coders may not follow the same ethical coding standards as you. If you observe unethical coding practices, bring it to the attention of the coder and allow them to make the needed adjustments. Broaching this issue with a colleague can be challenging but encourage the other coder to reflect on the ethics of their actions. If the unethical coding practices continue, be sure to inform the next person in command.
4. Keep in communication with the office manager. Loop your manager in when a peer conversation doesn’t resolve unethical behavior, or when a provider is unavailable to clarify documentation needed for coding.
5. Review notes from other health providers. Coders generally can’t code from documentation by anyone other than the provider, but ancillary staff notes (for example, a dietitian’s malnutrition assessment) can prompt you to query the provider - the code can only be assigned once the provider confirms the diagnosis.

Using the medical coding system allows providers to express the simplicity or complexity of a medical treatment or procedure. This specificity leads to the maximum reimbursement to the provider. The medical assistant must perform coding procedures accurately, so they exactly reflect what happened during the treatment. Codes must not be exaggerated to increase reimbursement to the provider.