Are you coding unspecified diagnoses?

With every year there becomes new specific diagnosis coding in the foundations of accurate risk adjustment coding. A few key concepts that providers should keep in mind include:

• Select the diagnosis codes that describe why the patient was seen AND also diagnosis codes for any chronic condition that affects treatment choices.
• A serious chronic condition with a manifestation or complication that has its diagnosis code. Don’t use unspecified when a known complication of the condition.
• Report diagnosis codes annually

Accuracy and specificity in the patient’s condition, along with patient engagement will help capture the serious condition of the patient.

Leaving money on the table due to improper documentation?

Are you leaving key information out of your documentation? Clinical documentation is essential in inpatient medical care. Improper documentation of one patient can mean a difference of about $10,000 a year or more. Medical documentation with deficiencies can cause all sorts of issues. Insufficient documentation can cause claims to be down-coded or denied, cause retraction of previous payments, or flag practice for prepayment review. Common documentation deficiencies that cause hang-ups are:

• Missing Pages within the documentation
• Physician orders/scripts are missing, incomplete, outdated, or illegible.
• Missing or wrong date of service
• Missing or improper CPT/ HCPCS level II modifiers
• Missing clinical/ medical necessity
• Unspecified diagnosis conditions or missing severity of the condition
• Undocumented procedures
• Missing details from the patient encounter
• Cloned documentation

It is important to keep an eye on commonly missed charges, such as supplies, devices, injections, infusion, vaccines, venipuncture, and whether the patient is new or established. Small errors can often add up the dollars of the revenue missed.

Be sure that your coding is compliant, not linking CPT, ICD -CM, and HCPCS level II codes correctly can hurt reimbursement. Be sure you are following all coding guidelines for your billing.

We are here to help within the Risk adjustment department, with helpful webinars, newsletters, and one-on-one talking points on specific topics.