A compliance task that each facility should perform to support the Health Information Management (HIM) department is performing coding audits. Coding audits are performed to access the accuracy of the diagnosis and procedures codes assigned to each patient’s chart. The timing of these audits can be performed monthly, quarterly, bi-annually, annually, or as often as the need arises at your facility. RMC performs coding audits for many facilities, ranging from physician’s offices to level 2 trauma acute care hospitals. In accordance with the Official Coding Guidelines (OCG), accurate coding cannot be achieved without clear, consistent, complete documentation in the medical record.

Common errors that RMC routinely notes are codes are being assigned by coders which lack specificity; however, the medical record documentation supports a more specific code. For example, the History and Physical documents chronic kidney disease, whereas the Progress Notes document chronic kidney disease stage 5. The coder would report diagnosis code N18.5 (Chronic kidney disease, stage 5) instead of diagnosis code N18.9 (Chronic kidney disease, unspecified). Use the current, full encounter physician documentation for the most specific code assignment. Additionally, coders must keep in mind the Conventions for ICD-10-CM as they govern code assignment. The relational term “with” or “in” have been problematic to many coding professionals. Per the OCG, the word “with” or “in” should be interpreted to mean “associated with” or “due to” when it appears in a code title, the Alphabetic Index (either under a main term or subterm), or an instructional note in the Tabular List. The classification presumes a causal relationship between the two conditions linked by these terms in the Alphabetic Index or Tabular List. We encourage each coder to routinely review the Alphabetic Index for diseases which have a “with” or “in” as a subterm as these can sometimes be difficult to identify in the encoder. A common diagnosis that has many subterms listed underneath “with” is diabetes. For instance, if medical record documentation states Type II diabetes and peripheral vascular disease, the combination code E11.51 (Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene) would be assigned and not E11.9 (Type 2 diabetes mellitus without complications) and I73.9 (Peripheral vascular disease, unspecified). Please remember, the most specific diagnosis code should be assigned!

In the outpatient setting, coders also need to ensure they are assigning the correct code as the first listed diagnosis. When reporting the diagnosis code, the coding professional should ask the question, why is the patient here? If the patient presents with more than one issue, which diagnosis was the reason for the visit? Coders also should be aware of things such as, was this an Outpatient Surgery encounter or was there a complication leading to an Observation stay. Those are all things to keep in mind when deciding what should be reported as the first listed diagnosis. Our Official Guidance informs us to list first the ICD-10-CM code for the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the services provided.

There are many more issues that we will dive into which include selection of principal diagnosis (etiology and manifestation convention), underdosing, reporting secondary diagnoses, those pesky psychoactive substance use codes, PCS code selection, CPT code selection, and more.

Reference: ICD-10-CM Official Guidelines for Coding and Reporting FY 2020