The Impact of Coded Data, Part 3: The Individual Patient

March 16, 2021

The Impact of Coded Data, Part 3: The Individual Patient

Excite welcomes you to the third article in a three-part series focusing on the uses and effects of medical coded data on three different levels: use by private agencies, healthcare providers, and the individual patient.

In parts 1 and 2, we talked about how important accurate data is to federal and private agencies for research and quality monitoring purposes. It is also important for healthcare providers for reimbursement, outcomes research and comparisons studies and marketing efforts.

In part 2, we offered an example of how inaccuracies in coded data can have serious consequences. The example involved provider documentation terminology, not coinciding with coding terminology, resulting in inaccurate reporting of post-operative complications. This led to the surgeon, and the hospital, having inflated post-operative complication rates leading to the appearance of poor quality of care.

In this article, we explore how inaccurate coding could potentially impact the patient.

Inaccurate coded data can be due to various things such as:

  • Coder mistake/ error, knowledge/ training/ skill
  • Provider documentation issues and terminology gaps with coding

PROVIDER DOCUMENTATION ISSUES AND TERMINOLOGY GAPS WITH CODING

  • Patient health insurance policies differ significantly in what is covered. In some policies, the insurance company pays up to 100% for an Emergency Department injury visit, while only 80% for a medical condition. For example, if a patient falls and experiences pain in the ankle with swelling and is seen in the ED for treatment— the X-ray reveals a possible hair line fracture to the tibia. The ED provider documents ankle pain. Ankle pain M25.579 falls into Chapter 13 Diseases of the musculoskeletal system and connective tissue. The insurance company pays 80% leaving 20% to the patient. The patient must assume the burden of requesting review of the documentation, correction of coding and rebilling so that the claim is paid correctly.

CODER MISTAKE/ ERROR, KNOWLEDGE/ TRAINING/ SKILL

  • Patient health insurance policies may differ significantly in what is covered. For example, when a patient is seen in the ED for a urinary tract infection, the coder who previously coded 3 back-to-back patients who were pregnant, might mistakenly assigned the patient with an obstetrical code for a UTI. The patient’s health insurance policy does not cover any pregnancy related conditions. The entire claim is denied. Again, the responsibility is placed on the patient to address the issue of incorrect coding, rebilling and reprocessing of the claim.

CODER MISTAKE/ ERROR, KNOWLEDGE/ TRAINING/ SKILL

  • Moreover, Medicare covers screening colonoscopies and reimburses hospitals based on the APC system. Not only is there a difference in how much the hospital is reimbursed for a screening versus a diagnostic procedure, but the patient’s out of pocket is impacted as well.
  • The copayment and deductible are waived for a screening colonoscopy, G0105, G0121. However, a diagnostic colonoscopy, 45378, has a 2021 fiscal year minimum unadjusted copay amount of $158.
  • A 65-year old Medicare patient presents to the outpatient endoscopy unit for a colonoscopy. The H&P states the patient has long-term bouts of diarrhea due to IBS, and that the presents for a screening colonoscopy. The colonoscopy has no findings. The coder reports diarrhea as the 1st listed diagnosis instead of screening, and CPT code 45378 diagnostic colonoscopy. The symptom of diarrhea is a longstanding symptom of a known condition— IBS. The reason for the colonoscopy was a screening, but because of the improper coding, the patient is faced with inappropriate responsibility for paying a co-pay for this service.

CODER MISTAKE/ ERROR, KNOWLEDGE/ TRAINING/ SKILL

  • Many coders are confused by the coding of tobacco use, abuse, dependence, current versus history of. While health insurers cannot outright deny coverage to smokers, they can charge them higher premiums than non-smokers. The justification for this is that smokers are more likely to develop health concerns in the future, and therefore represent a greater risk for insurance companies. Inaccurately assigning a patient as a current smoker on an encounter could impact their insurance premiums.

CODER MISTAKE/ ERROR, KNOWLEDGE/ TRAINING/ SKILL

  • Coding of drug and alcohol use, abuse or dependence can be confusing for many coders and the documentation at times does not help. Incorrect coding of these codes has negative implications for the patient. For example, a person is applying for a high-level government job that requires a security clearance. The incorrect coding of illegal drug usage or alcohol dependence could cause the person to fail the security clearance, losing the job opportunity. Similarly, a person is attempting to apply to the police program to become a police officer. The incorrect coding of drug usage could potentially disqualify them from program acceptance.

PROVIDER DOCUMENTATION ISSUES AND TERMINOLOGY GAPS WITH CODING

  • Following a car accident, a patient is seen in the ED for treatment of minor injuries. Her spouse was seriously injured and sent directly to the OR for surgery. The nurses take note the patient is anxious; therefore, the ED doctor orders something to help calm her nerves. The doctor then documents: minor head injury, sprained wrist, bruised rib cage, and anxiousness. The coder assigns the proper injury codes and adds F41.9 Anxiety disorder. F41.9 Falls into Chapter 5 Mental, Behavioral and Neurodevelopment disorders. The entire claim is denied by the insurance company stating that they do not cover for mental conditions. The patient is left to figure out how to address and get a revised/correct claim to the insurance company.

PROVIDER DOCUMENTATION ISSUES AND TERMINOLOGY GAPS WITH CODING

  • All 50 states require both physicians and laboratories to report to local or state health departments the names of persons newly diagnosed with AIDS. If an HIV test is positive, the clinic must report the results to the state health department. This allows public health officials to monitor HIV rates in their city and state.
  • Improper coding and reporting of HIV/AIDS not only has emotional impact for the patient, but it has detrimental results on research, data analysis and tracking of the disease process with treatments.
  • A part of the coder’s responsibilities at Example Hospital are coding outpatient labs based on the physician’s order. On one lab, the order reads AIDS/HIV. B20 HIV Disease was assigned by the coder. The patient was sent to the lab for an HIV test, which was negative. Providers need education on what to add to an order when they test to rule out a condition.
  • This patient was unaware of the incorrect code assignment. One year later when attempting to apply for a life insurance policy, he was denied due to having HIV in his health insurance documents.

Coders are typically under a lot of pressure to hit high production expectations. Some facilities are mainly concerned about coding for the right MS-DRG, APR-DRG and highest severity of illness level (SOI). Meanwhile, documentation issues persist, as evidenced by providers continuing to document bacteremia (positive blood culture without evidence of sepsis vs sepsis), urosepsis (UTI vs sepsis) and abbreviations with multiple meanings such as MS (mitral stenosis vs multiple sclerosis).

The provider’s primary focus should be patient care, not documentation. The coder’s primary focus should be complete and accurate coding, rather than production. Despite competing priorities, all must find a balance.

While coders and CDI specialists work with providers on the documentation detail, all organizations should focus on allowing coders an adequate amount of time to code as fully and completely as possible. As organizations establish production standards for coders, consider The Impact of Coded Data beyond reimbursement.

 

 

Lisa Marks, RHIT, CCS– VP of HIM Services

Robyn McCoart, RHIT– Managing Auditor