For those of us who work with coder

For those of us who work with coders as managers, auditors, co-workers, or consultants, we know how conscientious, dedicated, hard-working, and detail-oriented this group of professionals can be. When errors in their work are discovered, most are extremely upset with themselves and they work even harder to improve their coding skills. Although as humans we inevitably make occasional mistakes, an analysis of common errors found in auditing inpatient records suggests there are several reasons why coding errors are made. This article addresses some of the common coding errors and suggests some ways to prevent them. Knowing where the “traps” are should help to avoid them.
Carelessness: Choosing productivity as a priority over quality can cause a coder to rush through a medical record without thoroughly reading all available documentation. Additionally, the distractions and disruptions that occur in the environment may result in errors.
Encoder pathways: Coders who use clinical encoders during the coding process follow coding pathways to determine code and DRG assignments. As useful as these encoders are, they cannot prevent coding errors; following an incorrect coding pathway may result in an incorrect code assignment without the coder even realizing that an error has occurred.
Memorizing diagnosis and procedure codes: Experienced coders cannot help but memorize many code assignments after using them repeatedly. Sometimes, however, our memories fail and the direct entry of memorized codes may lead to error.
Incomplete or inadequate documentation: When documentation is incomplete or conflicting, it is difficult for the coder to code completely and accurately. Since coding is frequently completed before discharge summaries or other dictated reports are available, final conclusions/diagnoses may differ from those determined by the coder in reviewing History & Physical Reports and progress notes alone.
Incorrect principal diagnosis selection: Errors in selecting the principal diagnosis may be the result of a lack of knowledge of basic coding principles and terminology. The quality of the coder’s initial training program and/or “on-the-job experience” is fundamental to coder expertise, as is the coder’s ability to stay abreast of current coding guidelines. Misunderstanding or misinterpreting a coding guideline may also occur by failing to read encoder messages, inclusion and exclusion terms, and coding references during the coding process. Common examples of incorrect principal diagnosis selection include:
Coding a condition when a complication code should have been selected instead.
Coding a symptom or sign rather than the definitive diagnosis.
Assuming a diagnosis without definitive documentation of a condition.
Coding from a discharge summary alone.
Incorrectly applying the coding guidelines for principal diagnosis, especially in a situation where the coder selects the diagnoses when two or more diagnoses equally meet the definition of principal diagnosis.
Incorrect or missing secondary diagnoses: Secondary diagnoses are frequently coded when they do not meet the criteria for reporting secondary diagnoses. Some of the “traps” in coding secondary diagnoses are found in physician documentation. Examples include: (1) Using the term “history of” for conditions that are currently under treatment, as well as for those that have been resolved prior to admission; (2) Misusing the term “coagulopathy.” It is often documented when a patient on anticoagulant therapy has an expected prolonged prothrombin time, rather than a true coagulopathy. Secondary diagnoses may be missed by coders who code from a discharge summary alone without reviewing all documentation.
DRG assignment errors: In addition to the challenges of selecting the principal diagnosis and coding appropriate secondary diagnoses and procedures, failure to review the code list and DRG assignment may result in a DRG that does not “fit” with the patient’s stay.
RECOMMENDATIONS:
Focus on quality, not just productivity. The quality of coded data is more critical than ever before, given the use of these data and the extensive scrutiny of third party payers. This fact justifies taking the time to focus on coding accuracy and reading medical record documentation thoroughly. Try to eliminate as much of the daily distractions and disruptions in the workplace as possible.
To avoid encoder pathway errors, read the entire list of coding choices before continuing down the pathway, and then review the code assignment(s) to determine if the code selected seems to “fit” the condition or procedure. Use the ICD-9-CM coding manual as a reference tool, even when using clinical encoders.
Query conflicting and incomplete documentation. When a record has been coded without a final discharge summary, a process should be developed for reviewing them when it is complete. Remember that Recovery Audit Contractors and other external auditors have access to the entire medical record when a record request is received. If such final review of a discharge summary results in a different DRG assignment, the claim should be resubmitted.
Take time to read and analyze the entire medical record before finalizing code assignments; apply critical thinking skills when reviewing documentation and code assignments.
Review the official coding guidelines for principal diagnosis. When multiple conditions may be present or suspected on admission, it is especially challenging to determine if the guideline for two or more diagnoses meeting the definition of principal diagnosis may be applied.
Review current coding guidelines frequently, especially those topics that may be troublesome, such as respiratory failure, sepsis, complications of treatment, coagulopathy, and signs/symptoms.
Review all questionable code assignments with your supervisor or another coder; sometimes a discussion with another coder is enough to clarify your questions.
Query as necessary; be clear and concise and avoid “leading” physicians to a diagnosis.
Exercise care when coding secondary diagnoses from the History & Physical. Remember that the definition of “other diagnoses” for reporting purposes is conditions that affect patient care in terms of requiring clinical evaluation, therapeutic treatment, diagnostic procedures, extended length of hospital stay, or increased nursing care and/or monitoring. A condition that meets only one element of this definition may be coded; conditions that do not meet this definition should not be coded.
Review the completed code list and DRG assignment; this requires only a minimal amount of time and may prevent a DRG error.
The importance of accuracy in coding cannot be underestimated. As coders in the current data-driven healthcare environment, expectations are high and the challenges are many. Now is the time to assess your coding skills and use all resources available to improve them to ensure coded data of the highest quality.