Accurate coding is vital for hospitals and health systems. It ensures proper reimbursement, reflects quality patient care, and minimizes compliance risks. Yet, insufficient identification of coding issues can lead to costly recovery audits.
Here at ECLAT Health Solutions, we understand the importance of efficient coding practices. This article explores three common ICD-10 auditing mistakes and how to prevent them:
1. Inaccurate Clinical Documentation
The Problem: Incomplete or inaccurate clinical documentation leaves coders guessing. Without clear details, they may need to query physicians for additional information, leading to delays and potentially inaccurate coding.
The Solution: Encourage physicians to document diagnoses thoroughly and accurately. This ensures coders have the necessary information to assign the correct ICD-10 codes.
2. Missing Codes in Documentation
The Problem: Incomplete documentation can lead to missed codes. Just like a dictionary has specific terms, ICD-10 coding has its own set of codes. Missing crucial information can result in overlooking necessary codes.
The Solution: Emphasize the importance of complete patient documentation. Physicians should document all relevant diagnoses using the appropriate ICD-10-CM codes.
3. Insufficient Support for Assigned Codes
The Problem: Even with a clear diagnosis, coders rely solely on documented information. If a physician doesn’t document the diagnosis specifically, the appropriate code cannot be assigned. For example, if “sepsis” isn’t documented, the coder cannot assign the code, even if it’s the suspected diagnosis.
The Solution: Educate physicians on the importance of documenting diagnoses clearly and completely. Coders should not assume diagnoses based on incomplete information.
Experience Quality ICD-10 Auditing Results with ECLAT Health Solutions
Regular internal and external audits are crucial for identifying coding issues. But what if your team lacks the resources? ECLAT Health Solutions can provide expert ICD-10 auditing assistance.
Our team of experienced medical coders will conduct thorough and compliant audits, helping you:
- Identify and rectify coding errors
- Reduce the risk of costly recovery audits
- Establish a strong foundation for accurate coding practices
