Top 10 Documentation Coding Errors

This list of the ten most frequent coding errors is taken from the American Academy of Professional Coders (AAPC) from March 20, 2013. Check your coding against this list and avoid costly errors.

1) The record does not contain a legible signature with credential.

2) The Electronic Health Record (EHR) is unauthenticated (not electronically signed).

3) The highest degree of specificity was not assigned the most precise ICD-9-CM code to fully explain the narrative description of the symptom or diagnosis in the medical chart.

4) A discrepancy was found between the diagnosis codes being billed versus the actual written description in the medical record. If the record indicates "depression, NOS" (311 Depressive disorder, not elsewhere classified), but the diagnosis code written on the encounter document is "major depression" (296.20 Major depressive affective disorder, single episode, unspecified), these codes do not match; they map to a different Hierarchical Condition category (HCC). The diagnosis codes and the description should mirror each other.

5) Documentation does not indicate the diagnoses that are being monitored, evaluated, assessed/addressed or treated.

6) Status of cancer in unclear. Treatment in not documented.

7) Chronic conditions, such as hepatitis or renal insufficiency, are not documented as chronic.

8) Lack of specificity (e.g., an unspecified arrhythmia is coded rather than the specific type of arrhythmia.)

9) Chronic conditions or the status codes aren't documented in the medical record at least once per year.

10) A link or cause relationship is missing for a diabetic complication, or a mandatory manifestation code is not reported.

Primary Care Rate Increase

The Primary Care Rate Increase (PCRI) is effective for dates of service on and after January 1, 2013 through December 31, 2014. States are required by federal law to reimburse qualified providers at the rate that would be paid for the primary care service (if the service were covered) under Medicare.

A physician is eligible if he or she:

1) FIRST self-attests to practicing in the designated primary care specialties of Family Medicine, General Internal Medicine or Pediatric Medicine

AND

2) Is Board Certified in the designated specialties/subspecialties OR having a 60 percent paid claims history or both E&M codes and vaccine administration codes specified in the regulation.

The PCRI is not available for physicians, nurse practitioners or nurse midwives who are reimbursed through an FQHC, RHC, DTC or a facility's encounter, visit, or per diem rate or who are not practicing in one of the designated primary care specialities.

For more information, refer to page 3 of the CMS FAQ document, FFS Set III:
http://medicaid.gov/Steve-Resource-Center/FAQ-Medicaid-and-CHIP-Affordable-Care-Act-ACA-Implementation/FAQ-Medicaid-and-CHIP-Affordable-Care-Act-ACA-Implementation.html

Welcome

Please check back for updates.