The pdf focuses on certain important areas in the medical coding process where medical coders tend to err in spite of being focused on the job.

1. Tips to Avoid Poor Medical Coding
Practices
Accuracy is important in medical coding
because physician reimbursement, medical
data collection, hospital payments and
physician services all depend on the medical
codes. However, errors can occur any time –
even when the coders are focused on their
work, which is
usually a result of the
mechanical, routine
nature of the work.
To avoid poor coding
habits, there are a
few areas coders
need to identify and
improve. Accurate medical coding can benefit a
medical practice in many ways such as
improved patient care, on-time
reimbursement, reduced hassle of audits and
greater efficiency.
Let us look at some of the key areas where
medical coding errors are bound to happen.
Improper documentation - Often,
documentation by physicians is inadequate or
incorrect, and then it will be extremely difficult
for coders to ensure accurate coding. Coders
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2. have a habit of not going too much into the
details of medical records.
They simply browse or
speed read the documents
and code accordingly.
For instance, the main code
for pneumonia, SARS
associated corona virus is 480.31. But, the
coder in real terms may mistake it as viral
pneumonia and enter the code 480 for the
same, resulting in serious error. Coders should
be clear and informed about each and every
aspect of the codes entered for any health
problem.
In certain cases, coders with an objective to
increase their productivity do not give
adequate attention to the quality side.
Consequently, they may use unofficial
resources and spend less time reviewing all
documentation. They may solely depend on
physician dictation and may ignore the
associated notes. This can cause a coder to
rush through the codes before systematically
reading the documents, thus leading to coding
errors. Hence, verifying the medical records
and coding system in detail before assigning
any specific code is mandatory to avoid the
possibility of errors.
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3. Memorizing codes - Experienced coders may
happen to memorize several important codes
after using them repeatedly. They may enter
the codes out of their memory and not refer to
any other resources such as medical reference
books or journals. At times, their memory
power may fail, resulting in coding mistakes.
Creating cheat sheets - Coding cheat sheet
is a limited list of ICD-9 codes and their
descriptions. This is a good alternative for
coders to keep away from researching codes.
However, these resources are not constantly
updated (with specific details associated with
each code) and can become outdated or are
not all precise or detailed enough for accurate
diagnosis, leading to potential errors.
Incorrect principal diagnosis selection –
Lack of comprehensive knowledge about basic
coding principles and terminology results in
errors. The coding job experience and the in-
depth training undergone by coders will
determine their job expertise and also help
them stay updated about current coding
guidelines. Errors may also occur when coders
misinterpret a coding guideline. Incorrect
principal diagnosis selection includes –
• Applying the coding guidelines wrongly for
principal diagnosis (when the coder selects
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4. the diagnoses when more than two
diagnoses similarly meet the definition of
principal diagnosis)
• Coding a specific symptom or sign rather
than the definitive diagnosis
• Coding a symptom when a complication
code needs to be assigned
• Coding from a discharge summary alone
Using clinical encoders – Coders use clinical
software programs to follow coding pathways
to find out or research on specific codes and
DRG (diagnosis-related groups) assignments.
Even though software applications may allow
them to find codes easily, programs can be
defective. Coders may follow incorrect coding
pathway, resulting in incorrect code
assignment without even the coder realizing
that a specific error has happened. Hence, it is
highly recommended that coders find codes
through the code books even though it is a
time consuming process. The end result of
inaccurate coding depends mainly on how the
codes are used. Instead of relying on any
unauthorized websites for the latest medical
codes, it is advisable to search for up-to-date
codes at the CMS website.
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5. Proficient and experienced medical coders are
the hallmark feature of a reliable medical
coding company. This is why physicians who
choose to have their medical billing and coding
done professionally, benefit from the best
coding practices and accurate reimbursement.
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