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.