Clinical Documentation Provides Incorrect ICD-10 Codes
When the clinical documentation provided doesn’t provide the adequate information to specify the patient encounter accurately, medical coders will have to query the physician to obtain supplemental information or documentation to enter the accurate ICD-10 codes. If providers are not aware that they are providing incorrect ICD-10 codes, then those details must be addressed immediately as a patient’s diagnosis is extracted from the provider’s documentation. This may lead to the patient receiving inaccurate treatment because of the documentation wasn’t corrected beforehand.
Necessary Codes Not Included in Documentation
Facilities must ensure all patient documentation is complete and accurate as it will reflect the patient’s clinical conditions. For instance, physicians may use the coding set ICD-10-CM specifically for diagnosis coding. Using these codes may seem a bit overwhelming, but think of it as words in a dictionary where only certain words are used and not every single word.
Insufficient & Inconsistent Documentation Supporting the Assigned Code
Even though physicians may arrive at a diagnosis using a specific set of definitions or clinical criteria, the code is solely based on the physician’s documentation on the patient record and not the definition or criteria. This means, if a physician does not specifically document the diagnosis, the code cannot properly be assigned. For example, if physician records “sepsis” in the documentation, then the coders will assign that code to the patient. However, coders should not assume and assign medical codes on their own especially if there’s insufficient documentation. Although, if there is a failure to identify and address coding accuracy issues, this may increase recovery audits and place care initiatives based on value at significant risk.
Experience Quality ICD-10 Auditing Results with Mhites.
While the best way to prevent these trends mentioned above is by conducting ongoing internal and external auditing reviews, what happens if your team doesn’t have enough time to spare to identify these trends? Mhites can provide your healthcare facility with quality ICD-10 auditing assistance that’s needed to provide valuable insight and lessen coding issues caused by inaccurate coding assignments. Our medical coders will help you conduct regular coding audits that are accurate and align with compliance to create a much stronger foundation for the healthcare industry globally.
Receive proper auditing education and training as well as understand initial findings and results. Contact us today for more information on our ICD-10 auditing services!