Resolving Quality and Integrity Challenges in Medical Coding

Impact of Coding Errors on the revenue cycle

Coding errors can occur in various forms such as inaccurate choice of codes in ambiguous situations, usage of outdated codes, inconsistent interpretation of facts, misrepresentation of diagnosis/treatment details, absence of key information and/or due to the discrepancy between various versions of health records. Irrespective of the root cause, coding errors can result in denial of claims, delays in payment, partial payments and even loss of reputation for the provider through accusations of fraud/abuse. Ensuring a seamless and constantly updated coding team is crucial to optimize the healthcare provider revenue cycle, and for strict compliance with applicable regulations.

Commonly seen errors in Coding

• Upcoding: Claiming reimbursement for a treatment/procedure that is more expensive (due to higher complexity) than what was actually delivered to a patient. This exposes a healthcare provider to a risk of being accused of fraud or abuse
• Undercoding: Coding for a less expensive treatment/procedure than what was delivered to the patient, resulting in a loss of revenue for the provider
• Unbundling: Assigning individual codes for multiple procedures which are supposed to be billed with an umbrella code covering the full set of procedures
• Outdated code sets: Failure to maintain the latest code sets, and lack of training to update the knowledge of medical coders will lead to use of invalid/expired codes even for common procedures, resulting in denial of claims and loss of revenue

Strategies for enhancing Coding quality

• Regular training for coding team: Medical coding protocols are continually evolving, and coding professionals have to be educated on an ongoing basis about new codes, documentation guidelines and revisions to existing code sets. Investing in an effective program will bring significant returns in terms of coding accuracy and thereby claim acceptance rates
• Continuous monitoring and auditing: Frequently auditing the organization’s coding standards and claims documentation practices can help identify and address any errors before they escalate and have any revenue impact. This should be in accordance with industry accepted coding guidelines and must be periodically reviewed to ensure validity.
• Technology solutions: Computer-assisted coding (CAC) and automation tools can help streamline the coding process and improve the accuracy of a coding team’s output. The use of Artificial Intelligence and Natural Language Processing opens up new possibilities in this field.
• Collaborative communication: Establishing proactive communication between the healthcare providers and coding professionals will promote better quality of coding output, especially by eliminating errors arising from clinical documentation issues. Coders must have the opportunity to clarify immediate issues and ambiguities, and over time this should enhance documentation quality.