More than 4,000 cases were coded in the 2019 contest focused on outpatient coding.
ICD-10 is well-established, and we are already discussing and planning for ICD-11. However, where are the long-anticipated and promised increased accuracy and most definitive diagnoses? At least one coding contest found outpatient coding in 2019 had the worst accuracy to date. How can that be true? Is suboptimal coding creating a trickle-down effect seen in audits, compliance, payments, and payor findings?
ICD-10 has enormous specificity that apparently has not been captured as anticipated. Prior to implementation, it was believed to be the pathway to better and more accurate coding, disease management, epidemiology, causes of morbidity and mortality, and robust healthcare statistics. Enormous amounts of time are focused on clinical documentation improvement. Coders have intensive training. So why have the expected improvements not been realized?
Central Learning has held an annual coding contest, beginning in 2016. Overall accuracy trending results were 38 percent, 41 percent, 42.5 percent, and 40.4 percent, chronologically. Coders self-designate their area(s) of expertise and years of experience. Actual redacted medical records were relied upon for the contests.
Due to the significant increases in outpatient services and shifts in payment methodologies, the 2019 contest focused on outpatient coding. More than 4,000 cases were coded. A total of 81 percent of the contestants were American Health Information Management Association (AHIMA) and/or AAPC certified. A total of 82 percent of the contestants had more than five years of coding experience. The surprising finding was an accuracy rate of 60.5 percent for primary diagnoses, and only 38.6 percent for secondary diagnoses. Analysis indicated a lack of specificity in the primary diagnosis and failure to follow coding principles and guidelines in secondary diagnoses.
As I pondered these findings, so many questions arose. Are the coding tools relied upon by contestants faulty, a Herculean task to navigate, or lacking the coding guidelines? In our business, we see significant volumes of incorrect coding in data feeds every single day. Were records incomplete, missing information, or lacking sufficient detail? We know many often are. Are bad habits ingrained when coders are pressured to code what they have and not “bother” the physicians for clarification? Are production benchmarks too high to allow time to maximize coding accuracy? Are coders used to (or trained to) rely upon electronic health record (EHR) code assignment, a method fraught with errors? Whether or not any of these questions actually apply to the contest, they are certainly facts in everyday billing and coding.
Much has been published about “surprise billing,” and new state laws are the norm, pending federal legislation. While the focus has been on out-of-network physicians, the fact is that outpatient diagnosis coding has a direct bearing on insurance coverage. Is one of the identified errors, lack of accurate secondary diagnoses and the etiology or reason for the visit, also a cause of surprise bills?
We know most entities and providers are experiencing significant increases in medical record requests. Could the coding contest findings be a major contributor to that trend? Incomplete accident or injury information, lack of specificity, and CPT versus diagnosis apparently mismatching all can contribute to record requests. Likewise, diagnoses that do not appear to support the level of a visit are always a red flag. As more payors use proprietary analytics to evaluate medical necessity, the most accurate and complete diagnosis coding is of the utmost concern.
The Central Learning annual contest continues to raise serious questions that should be given a thoughtful consideration. How and why are certified, experienced coders, with specialty expertise, unable to knock it out of the park?
In addition, this raises questions that are more global. Coding does not occur in a vacuum. Is provider documentation that bad, in spite of all the clinical documentation improvement efforts? Are production benchmarks too high to have the maximum coding specificity? Are coding tools antiquated or scaled down to the point that they no longer accurately represent the authoritative coding guidelines and conventions? Have we fallen into the trap of relying too heavily on technology instead of thinking humans to do the heavy lifting? Are our coders divorced from denials and the outcomes of medical record review requests? Do patient complaints about surprise bills that result from poor documentation and/or suboptimal coding get openly shared with those involved?
In my humble opinion, this is not just a coding contest accuracy question. That is one piece of a very big picture. Let us look at the whole picture, because something is wrong if this is the best we can do, four years after ICD-10 implementation.
Programming Note:
Listen to Holly Louie report this story live today during Talk Ten Tuesday, 10-10:30 a.m. EST.
https://www.centrallearning.com/wp-content/uploads/2019/09/2019-CL-results.pdf
In a recent article, I described a documentation environment governed by two distinct and often competing controlling systems. The first is the regulatory framework established
Coders may very well feel that they have no impact on hospitals under H.R.1, the so-called One Big Beautiful Bill Act (OBBBA). Just the opposite
Please log in to your account to comment on this article.
Sepsis sequencing continues to challenge even experienced coding and CDI professionals, with evolving guidelines, documentation gaps, and payer scrutiny driving denials and data inconsistencies. In this webcast, Payal Sinha, MBA, RHIA, CCDS, CDIP, CCS, CCS-P, CCDS-O, CRC, CRCR, provides clear guideline-based strategies to accurately code sepsis, severe sepsis, and septic shock, assign POA indicators, clarify the relationship between infection and organ dysfunction, and align documentation across teams. Attendees will gain practical tools to strengthen audit defensibility, improve first-pass accuracy, support appeal success, reduce denials, and ensure accurate quality reporting, empowering organizations to achieve consistent, compliant sepsis coding outcomes.
Expert presenters Kathy Pride, RHIT, CPC, CCS-P, CPMA, and Brandi Russell, RHIA, CCS, COC, CPMA, break down complex fracture care coding rules, walk through correct modifier application (-25, -57, 54, 55), and clarify sequencing for initial and subsequent encounters. Attendees will gain the practical knowledge needed to submit clean claims, ensure compliance, and stay one step ahead of payer audits in 2026.
Accurately determining the principal diagnosis is critical for compliant billing, appropriate reimbursement, and valid quality reporting — yet it remains one of the most subjective and error-prone areas in inpatient coding. In this expert-led session, Cheryl Ericson, RN, MS, CCDS, CDIP, demystifies the complexities of principal diagnosis assignment, bridging the gap between coding rules and clinical reality. Learn how to strengthen your organization’s coding accuracy, reduce denials, and ensure your documentation supports true medical necessity.
Denials continue to delay reimbursement, increase administrative burden, and threaten financial stability across healthcare organizations. This essential webcast tackles the root causes—rising payer scrutiny, fragmented workflows, inconsistent documentation, and underused analytics—and offers proven, data-driven strategies to prevent and overturn denials. Attendees will gain practical tools to strengthen documentation and coding accuracy, engage clinicians effectively, and leverage predictive analytics and AI to identify risks before they impact revenue. Through real-world case examples and actionable guidance, this session empowers coding, CDI, and revenue cycle professionals to shift from reactive appeals to proactive denial prevention and revenue protection.
Federal auditors are intensifying their focus on inpatient psychiatric facilities, using advanced data analytics to spotlight outliers and pursue high‑dollar repayments. In this high‑impact webcast, Michael Calahan, PA, MBA, Compliance Officer and V.P., Hospital & Physician Compliance, breaks down what regulators are really targeting in IPF-PPS admissions, documentation, treatment and discharge planning. Attendees will learn practical steps to tighten processes, avoid common audit triggers and protect reimbursement and reduce the risk of multimillion-dollar repayment demands.
In this timely session, Stacey Shillito, CDIP, CPMA, CCS, CCS-P, CPEDC, COPC, breaks down the complexities of Medical Decision Making (MDM) documentation so providers can confidently capture the true complexity of their care. Attendees will learn practical, efficient strategies to ensure documentation aligns with current E/M guidelines, supports accurate coding, and reduces audit risk, all without adding to charting time.
Join Ronald Hirsch, MD, FACP, CHCQM for The PEPPER Returns – Risk and Opportunity at Your Fingertips, a practical webcast that demystifies the PEPPER and shows you how to turn complex claims data into actionable insights. Dr. Hirsch will explain how to interpret key measures, identify compliance risks, uncover missed revenue opportunities, and understand new updates in the PEPPER, all to help your organization stay ahead of audits and use this powerful data proactively.
Stay ahead of the 2026-2027 audit surge with “Top 10 Audit Targets for 2026-2027 for Hospitals & Physicians: Protect Your Revenue,” a high-impact webcast led by Michael Calahan, PA, MBA. This concise session gives hospitals and physicians clear insight into the most likely federal audit targets, such as E/M services, split/shared and critical care, observation and admissions, device credits, and Two-Midnight Rule changes, and shows how to tighten documentation, coding, and internal processes to reduce denials, recoupments, and penalties. Attendees walk away with practical best practices to protect revenue, strengthen compliance, and better prepare their teams for inevitable audits.
Prepare for the 2025 CMS IPPS Final Rule with ICD10monitor’s IPPSPalooza! Click HERE to learn more
Get 15% OFF on all educational webcasts at ICD10monitor with code JULYFOURTH24 until July 4, 2024—start learning today!
CYBER WEEK IS HERE! Don’t miss your chance to get 20% off now until Dec. 1 with code CYBER25
CYBER WEEK IS HERE! Don’t miss your chance to get 20% off now until Dec. 2 with code CYBER24
