Coding Compliance: Some Lessons Learned

The errors identified through coding audits really are a lesson to learn.

EDITOR’S NOTE: This article first appeared in the RACmonitor edition of the Saturday Morning Post, March 12, 2022.

We all can learn from the past, right? Human nature tells us to do so. This is also true when it comes to healthcare and coding compliance. Haven’t you seen, read, or heard about common coding errors – mistakes that impact reimbursement and overall compliance? Mistakes that impact data quality? I’m sure the answer is “yes” – I know I have.

Mistakes do happen in life, and certainly at work. As healthcare professionals, we all strive to comply with rules, regulations, and official guidance. For the health information management (HIM) professional, there are ongoing audits and education to ensure accuracy and that coding is compliant. Nationally, it is said that 95 percent or higher is the target for coding accuracy. But I often think that metric is too low, and our goal should be higher. I think about this in the context of, would we allow 5 percent of passenger planes to crash? I don’t think so. Or would we accept 5 percent of the food we purchase to be contaminated? I don’t think so. So why are we accepting a 5-percent error rate when it comes to coding and the associated reimbursement? Keep in mind that this error rate represents both over- and under-coding, or both over- and under-payments. The overpayments, of course, mean we take on significant compliance risk, and refunds will need to take place. The errors identified through coding audits really are a lesson to learn, no matter how big or small.

I can recall a validation review I was charged with conducting on coded data submitted to a state, entailing the investigation of a state report that indicated several coding “flags” (errors) when it came to the codes for hypertension and renal failure in the same encounter. The hospital inpatient and outpatient data showed that these two diagnoses were being coded separately, not as a combination code, as the Official Guidelines instruct.

Upon further investigation and review of 60 inpatient encounters, yes, I found that these two diagnoses were indeed being coded separately. How could this be? The coding rules are clear, that there is an assumed relationship between these two conditions, and we are required to use a combination code. This led to the revelation that these encounters were all coded by the same contracted coding staff member, who had been at the facility for more than five years. The next step was to discuss this with the individual. We came to find out that the reasoning was that this individual did not support the Official Guidelines that gave the instruction to use a combination code.

Wow, what a shock that was to me. Was I hearing that correctly? Yes, I was! Well, the encounters still had to be corrected, and the individual who made the mistakes was instructed to correct all of them. That individual learned a lesson: that you must always follow the Official Guidelines. Our hospital HIM department also learned a lesson: that we need to screen our contracted coding staff more closely, and ensure that they are following Official Guidelines. This resulted in us using an attestation statement for all contracted coding staff, indicating that they will always follow the Official Guidelines. Of note is that these errors did not impact reimbursement, but it did impact overall data quality and accuracy!

A great quote regarding mistakes is this: “mistakes have the power to turn you into something better than you were before.” –Anonymous

“Integrity” is a word that comes up a lot in healthcare, especially with regard to clinical coding, clinical documentation, and compliance. According to two online dictionaries, we find the following meanings for integrity:

Merriam-Webster:

• the quality of being honest and having strong moral principles; moral uprightness.
• “he is known to be a man of integrity”
• synonyms: honesty · uprightness · probity · rectitude · honor · honorableness

Free Dictionary:

• Steadfast adherence to a strict moral or ethical code: a leader of great integrity.
• The state of being unimpaired; soundness: The building’s integrity remained intact following the mild earthquake.
• The quality or condition of being whole or undivided; completeness: replaced a lost book to restore the integrity of his collection.

Another recent scenario also comes to mind: when an auditor was presenting outpatient evaluation and management (E&M) CPT® audit findings with a client and found that there were errors changing the E&M level about half of the time.

Such audit findings should be presented and discussed in a clear manner, with the inclusion of a rationale for the finding or coding change(s). There needs to be an opportunity for the client (hospital or department) to dispute the findings, often reviewed to as a “rebuttal.” This is all well and good, but what do you do when the client says, “we want the accuracy changed, we don’t want to count those E&M one-level changes as errors?”

I think you’d agree that the usual and customary practice when auditing is that if an E&M-level CPT code is changed to even one level higher or one level lower, this constitutes an error. The statement the client often makes is that, if followed, this will certainly impact the overall accuracy rate, potentially making it better than it actually is/was. So, before starting an audit, both parties should meet to discuss how a coding error or variance will be determined or counted, so there are no surprises. If you fundamentally disagree with your client in their recommended practice, then maybe this is not a client for you. This could be is a hard lesson to learn, and you could lose potential income from performing the audit for this client, but stick to your integrity and do not waver.

Another wonderful quote from Martin Luther King, Jr. comes to mind: “the time is always right to do what is right.”

I think about this quote often, as it can really resonate across healthcare, and certainly within coding compliance. So, yes there are lessons to learn, and please think about those you’ve learned this past week. Do we need to focus more on what is right, what is ethical, and what is proper? There certainly are many pressures, many options, and many differences of opinions to consider, but doing what is right is the cornerstone of coding compliance and integrity itself!