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What is a coding error?

HIM-HIPAA Insider, July 6, 2015

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The American Medical Association (AMA) is pushing for a two-year safe harbor for physicians so the doctors won’t be penalized for “errors, mistakes, and malfunctions relating to the transition.”

That’s pretty vague language (something coders hate). What exactly constitutes an “error” or a “mistake”? Is it something as simple as reporting H65.01 (acute serous otitis media, right ear) when you should have reported H65.02 (acute serous otitis media, left ear)? I can see that happening. I can also see a lot of coders reporting H65.00 (acute serous otitis media, unspecified ear).

Incorrect or unspecified laterality is a simple mistake, probably caused by lack of familiarity with the codes or a lack of documentation. The payment isn’t going to change, so you may think of it as “no harm, no foul.” And you would be right, to a point. A problem could arise when the patient comes in for a follow-up visit and the physician is checking the wrong ear. The patient may remember and correct the physician or maybe not.

Not all errors or mistakes are so minor. Consider what happens when you report I13.2 instead of I31.2.

The patient goes from a diagnosis of hemopericardium, not elsewhere classified (I31.2) to a diagnosis of hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end-stage renal disease (I13.2). Very different conditions with very different clinical pictures and different treatment.

If the AMA had its way, presumably, the physician would still be paid, but we don’t know for which diagnosis. Would the physician receive payment for I13.2, the reported diagnosis, or I31.2, the correct diagnosis? The AMA doesn’t say.

Another thing to consider is the cause of the error or mistake. Did the coder simply select the wrong diagnosis code or transpose characters in the code?

Or did the physician not document enough information, so the coder made a best guess rather than send a query?

Maybe the physician was actually assigning the codes because he or she does not employ a coder or a coding service. In that case, the physician may have missed guidelines, sequencing rules, and additional codes. After all, the physician is trained to treat patients. The best solution to that problem is to hire a certified coder (or a reputable coding company).

I’ve repeatedly heard the argument that small physician practices can’t afford to hire a coder. According to the 2014 JustCoding Salary Survey, the largest percentage of coders earns $40,000–$49,999. Of course, part of that depends on the area. Coders in rural areas will make less than coders in big cities.

The advantages of hiring a professional coder can outweigh the investment in salary and benefits. For example, a certified coder may catch reportable diagnoses that the physician hasn’t been coding. Or the coder may improve reporting of modifiers, which helps reduce denials and speeds up reimbursement. The biggest benefit, though, is that the physician has more time to practice medicine.

A two-year free ride isn’t the answer to helping physician practices through the transition. All it does is encourage physicians to continue dragging their feet on ICD-10 implementation. The AMA isn’t helping physicians with its continued push to delay (either outright or through the safe harbor) ICD-10.

Physician practices or facilities, for that matter, that are still not ready have 99 days to prepare. Use the time wisely instead of hoping for a free ride.

This article originally appeared on HCPro’s ICD-10 Trainer blog.

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