Coding 101: Common Pitfalls and How to Avoid Them

Each stage in life has a sequence of knowledge and application. If we follow the steps, we may avoid situational pitfalls.

Medical coding, the communication mechanism for healthcare reimbursement and the standardization of uniform language for nationwide claims processing of medical, surgical, and diagnostic items and services, can be complicated to understand and apply. It can be challenging to gain a further understanding of the intricacies of Centers for Medicare & Medicaid Services (CMS) guidance as well as coding technology, artificial intelligence, reimbursement methodology, and general processes and procedures to maintain compliance and avoid the many opportunities for violation.¹

To combat challenges and drive coding uniformity and proper claim submission, the ICD-10 coding guidelines provide a framework for application to ensure that appropriate code capture occurs, in this age of specificity, to the highest possible level of clarification. One can almost feel, see, and experience the medical diagnosis from the medical record documentation as if it were their own. With a surplus of information available at the click of a button, it’s easy to wonder how an organization could end up with claim rejections, claim denials, upcoding, unbundling, inadequate application of coding guidelines, compliance issues, and lack of clarification to name a few common mistakes that medical coders and healthcare professionals make day in and day out. Common pitfalls can be avoided through awareness of industry rules and regulations, effective communication, and a robust compliance plan.

Industry Rules and Regulations

Before documenting a medical record or coding a healthcare encounter, healthcare professionals must be proactive and have knowledge of regulations, requirements, guidelines, and governance. Much like the rules of the road, there are rules to coding that, if not followed, will result in adverse outcomes for the patient, the organization, and healthcare. More commonly than not, medical record documentation must include integral components, allowing a potential domino effect on medical coding submission. One must be aware of the essential joint effort between the healthcare provider and the medical coder to produce the most complete, most valid, most accurate code assignment and diagnoses and procedures report.¹

Coding professionals will need to be aware and proactive to ensure that there is a thorough understanding of guidelines for coding and reporting, including National Correct Coding Initiative edits, Local Coverage Determination, National Coverage Determination, procedural coding guidance, organizational guidance, and other regulations, before engaging in medical coding and claims submission. To be proactive, organizations should have in place proper professional coding compliance staff to combat potential issues and educational staff to ensure appropriate maintenance of knowledge of ever-changing coding guidelines and industry standards. To remain proactive and avoid common pitfalls, coding professionals should stay up to date with the most recent coding guidelines and industry standards, complete a thorough review of medical record documentation, select only the most appropriate codes based on the documentation, seek clarification of ambiguity directly from the healthcare provider, and double-check work for accuracy and completeness before submission. The organization should also have a denial and rebuttal process to use when rejections or failures occur.

Communication

Have you ever been in a morning team huddle, a team meeting, or a conversation with a colleague and felt that others were missing your point or dismissing your input? Do you feel like you need help getting your point across? Are you a biller, coder, office manager, or provider speaking a language that the other professionals seem not to grasp? This is likely because one of the main reasons that common pitfalls occur in coding is the need for more dynamic communication.²

Lack of communication can lead to frustration, misinterpretation, a tense work environment, negative performance, and ultimately, incorrect capture of medical coding, which can directly impact patient care. To avoid this pitfall in your day-to-day coding, communication needs to transmit information to the listener by identifying your needs, identifying the issue, if any, and determining what is required from the other party. Try to avoid reacting emotionally; take the initiative and ownership of being transparent, knowledgeable, and objective.²

Be concise and compelling. Make requests for a query for documentation direct, simple, to the point, and within the confines of the American Health Information Management Association Guidelines for Achieving a Compliant Query. Focus all your attention on getting to the end of the diagnostic clarification and provide a solution to evolve or build communication processes. For example, if there is a lack of ability to communicate to determine the highest level of specificity for diabetes, or you need to know if a hypertensive and diabetic patient has retinopathy due to, or not due to, one of the conditions, ask the other party what they need to help provide this information. Listen, explain the scenario’s importance for you, express your expertise, negotiate, get a clear understanding, be involved in the conversation, and share your thoughts or knowledge about the matter.

Effective and clear communication is a significant skill that is an essential and continuous developmental practice. Communication not only helps to strengthen the workplace and the teams involved in the work, but it also benefits the fullness of the patient’s visit to a healthcare organization. Common coding pitfalls that lack documentation, medical necessity, or specificity may stem from a lack of proper, complete, and effective communication. It is essential to understand the bridges and connections that are built through communication. Ensure completeness by using the 5 C’s of communication: be clear, concise, compelling, curious, and compassionate.² Effective communication can support pitfall avoidance and lead to the achievement of successful patient, provider, claim, and professional outcomes.

Compliance

CMS has reported that 58% of medical claims were not properly coded, resulting in more than $400 million in overpayment.³ This caused a domino effect on the healthcare system, healthcare organizations, and, most importantly, the patient. However, incorrect coding, even to the point of a simple mistake, could cause an organization to lose 12% in revenue annually.³ A robust healthcare compliance program will help to reduce and resolve any potential coding pitfalls that could be detrimental to a healthcare organization.

Healthcare compliance programs have important benefits in addition to their obligation to prevent fraud and abuse; these programs support patient safety, continuity of care, and favorable outcomes, while helping to improve operational efficiency and avoid legal risks.⁴ Compliance in healthcare can be a confusing and convoluted space; however, it is one worth exploring and becoming comfortable with.

Each healthcare organization should establish a compliance program that involves a fluidly arranged set of policies, procedures, measures, objectives, and laws that apply directly to their billing and coding processes. The goal here is to understand, communicate, and make available all applicable laws, regulations, and standards of ethics. Understanding which procedure codes are bundled, what it means to see that a code has an Excludes 1 note, and how to apply a global period to a claim prior to submission will avoid severe fraud, waste, and abuse consequences. Compliance programs also ensure the patient’s well-being and deter fraudulent behavior through internal controls of coding edits, coding and compliance internal and external audits, and ethical standards of practice across the board.⁵ A healthcare organization with an established compliance program shows a commitment to the healthcare field through ethics, training, and promoting patient well-being and will not only avoid common coding pitfalls but will also earn and maintain the trust of regulatory bodies, payers, key stakeholders, and most importantly, patients.^2,4

Understanding no one is perfect, organizations that utilize healthcare coding claim submissions can excel by avoiding common pitfalls through awareness and application of industry rules and regulations, the 5 C’s of communication, and a documented, applied, and robust compliance plan.

References

1. Centers for Medicare & Medicaid Services. Coding. Updated September 10, 2024. www.cms.gov/cms-guide-medical-technology-companies-and-other-interested-parties/coding
2. Keates C. The five C’s of effective communication. Forbes Coaches Council. September 10, 2018. www.forbes.com/councils/forbescoachescouncil/2018/09/10/the-five-cs-of-effective-communication/
3. Babst M. HCC coding compliance: avoid revenue loss and fines in healthcare. The Coding Network. January 12, 2024. https://codingnetwork.com/hcc-coding-compliance-avoid-revenue-loss-and-fines-in-healthcare/
4. Amod F. Benefits of a compliance program in healthcare. Paubox. December 13, 2023. www.paubox.com/blog/benefits-of-a-compliance-program-in-healthcare
5. O’Reilly KB. 8 medical coding mistakes that could cost you. September 18, 2023. www.ama-assn.org/practice-management/cpt/8-medical-coding-mistakes-could-cost-you

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