Production Coders

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“In my experience, when coders are required to meet production levels, the coding is less specific.”

What?

The quote was made by an auditor who recently performed retrospective audits (claims already billed and probably adjudicated as either paid, denied, or pending.

I agree, but I’m going to say it differently and provide the background.

Most coders are held to production standards to meet revenue cycle requirements. 

A coding contracting company that is paid per chart/encounter coded is not getting paid until the coding is done.

For a medical practice, private or hospital-based, you need the codes to submit the claims, so the payments come in.

During the review, the auditor identified claims with “unspecified” diagnosis codes submitted or denied as not coded to the highest level of specificity.

Examples included:

1. Missing laterality or reporting observation Z codes  – According to ICD-10-CM Coding Guidelines (2021), “If the side is not identified in the medical record, assign the code for the unspecified side.”

In the 2022 update, “When laterality is not documented by the patient’s provider, code assignment for the affected side may be based on medical record documentation from other clinicians. If there is conflicting medical record documentation regarding the affected side, the patient’s attending provider should be queried for clarification. Codes for “unspecified” side should rarely be used, such as when the documentation in the record is insufficient to determine the affected side and it is not possible to obtain clarification.”

“As stated in the introductory section of these official coding guidelines, a joint effort between the healthcare provider and the coder is essential to achieve complete and accurate documentation, code assignment, and reporting of diagnoses and procedures. The importance of consistent, complete documentation in the medical record cannot be overemphasized. Without such documentation accurate coding cannot be achieved. The entire record should be reviewed to determine the specific reason for the encounter and the conditions treated.”

For reporting observation codes to rule out conditions, according to ICD-10-CM guidelines, “There are three observation Z code categories. They are for use in very limited circumstances when a person is being observed for a suspected condition that is ruled out. The observation codes are not for use if an injury or illness or any signs or symptoms related to the suspected condition are present. In such cases the diagnosis/symptom code is used with the corresponding external cause code.”

Suppose the practice is not providing documentation feedback to the providers to document to the highest level of specificity or to document the signs/symptoms that require study. Instead, the coders must locate other documentation that specifies laterality or submit queries to the providers for signs/symptoms and wait for responses. In that case, production coders should not be penalized for lower productivity.

The coding is only as accurate as the documentation supports.

When coders are pushed to “just code,” you have to ensure that providers are educated on the importance of specificity in their documentation.

Otherwise, coders are meeting productivity benchmarks, but what does it matter if the claims are returned for more specific diagnoses?

Denials and Appeals

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How many medical coders know the outcomes of the services that they code?

Was it paid, or was it denied?

Are you receiving feedback from the A/R team?

Are you assigned a denials work queue for coding review and appeals?

I’m from the generation of medical coders who started on the medical billing side. 

We did the charge entry, the insurance follow-up, and the payments and denials posting.

These are examples of denials that coders should review:

• code is inconsistent with the modifier used or required modifier is missing
• missing/incomplete/invalid procedure code(s)
• missing/incomplete/invalid diagnosis or condition
• non-covered/not medically necessary
• services are included in another procedure/service

Now, before you remind me that this is 2022, not 1992, it’s my opinion that we are too dependent on automation, and as a result, coders may lack core skills that can make them well-rounded.

I’ve always believed that coders with A/R background make the strongest coders.

This does not mean that someone entering the coding arena without the A/R background is not a good coder. In my experience, coders who have experience in the entire revenue cycle understand the impact of each part, can work coding denials, and submit appeals for incorrect denials.

Most software will scan your codes and show you the problem with the coding before the claims are submitted. These are called claims edits.

Even with the software, the practice may still have denials on the back end.

So, you have A/R staff working on coding denials.

When I worked on the A/R side (before going to the coding side), I had to work on a claim with a coding denial. I reviewed the denial with the coder because we needed to file an appeal. The coder told me to file an appeal.

All I needed the coder to do was review her coding and if she disagreed with the payer’s denial, give me the reason(s) why the denial was incorrect. If she agreed with the rejection, I needed her to correct her coding. Instead, she told me again to file an appeal.

That was when I realized that coding denials have to be reviewed and, if necessary, appealed by coders.

You coded it, so defend your codes.

So, what’s the purpose of this? 

If you are new to the coding industry and are looking for your foot-in-the-door opportunity, look to the medical billing side to establish a firm foundation. 

With your coding skills, you may find your specialty is coding denials management.

Let me know your thoughts!

K.

ICD-11

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I’m hearing a lot of chatter about ICD-11. 

I have not been concerned about the coming changes because we survived the change from ICD-9-CM to ICD-10-CM. However, after reviewing the ICD-11 coding tool and the ICD-11 Training Package, I have concerns.

Have you reviewed the training? 

Don’t worry.  The United States has not implemented ICD-11 yet, and if ICD-11 follows the path of ICD-10, we (in the United States) have plenty of time to learn.

 What are your thoughts?