Five Biggest Medical Coding Mistakes You Can Avoid

“Oops! That’s my mistake”. “No problem, everybody makes mistakes”. “But I am a medical coder”. “What?!!! You are a criminal”!
Everybody makes mistakes. But not a medical coder! Medical coders are counted as among the most meticulous and careful professionals. Any mistakes they make directly impact the financial revenue of hospitals and the processing of medical claims by insurance companies. Despite their dedication to accuracy, stress associated with deadlines and matters of productivity may sometimes leave them vulnerable to making mistakes. Here are five biggest mistakes that you can avoid during your regular tryst in the frightening yet incredible world of medical coding.

1.     Mistake #1: Depending on Memory

Okay…so you have a great memory. Working for hours in the field, you are bound to memorise codes for a number of repeated procedures. But we’ll tell you – coding from memory is one of the biggest blunders! Coders tend to memorise basic codes and no longer rely on reference books, skimming medical records only superficially. Falling into routine, they may simply over-rely on coding software, memory based coding and cheat sheets. However, when coding from memory, you may run the risk of putting in the wrong codes because all medical conditions, procedures, etc. vary from case to case.
For instance, if you wrote the direct code for CHF (congestive heart failure) several times, you are bound to remember the code and use it every other time. However, if you read the documentation carefully, it may actually say that a patient was diagnosed with systolic CHF, which has a different code. Similarly, there are different codes for hypertension and malignant hypertension. Simply recalling codes from memory and keying them in is thus a hazard. Make sure you read the documentation carefully and find out the correct codes from reference books rather than merely using shortcuts.

2.     Mistake #2: Incorrect Selection of Principal Diagnosis

Lack of enough knowledge of coding terminology and principles, or lack of considerable experience may result in incorrect selection of the principal diagnosis. Coders may tend to code a complication as a condition, a definitive diagnosis as a symptom, or assume a diagnosis without the condition’s definitive documentation. They may also code only from the discharge summary rather than the entire documentation. Such misinterpretation of coding guidelines may occur when coders do not read the encoder messages, coding references, editor’s notes and inclusion and exclusion terms carefully. To avoid this blunder, coders should stay up to date on coding guidelines and should carefully read the reference books, accompanying editor’s remarks, and the medical documentation of the patient completely.

3.      Mistake #3: Incorrect Use of Modifiers

The misuse of modifiers is one of the most common coding mistakes, especially that of modifier 25. Modifier 25 indicates that a separate E&M (Evaluation and Management) service in addition to a minor surgical procedure was performed by the physician for the patient on the same day. If this modifier is simply used to code for the decision making portion of the patient’s visit, it is a gross error.
For instance, when a physician determines that a particular head trauma patient requires sutures, and confirms his immunization and allergy status, obtains informed consent and carries out the repair procedure, it is not considered as an E&M service and modifier 25 is not to be used in this case. However, if the physician also carries out a necessary full neurological examination, it may be reportable as a separate E&M service. Many minor surgical procedures have a global 10 day surgical period during which any follow up services for that procedure do not qualify as separate services. For major surgeries, a 90-day global surgical period applies.
Sometimes, coders also mix up modifiers 51 and 59. Modifier 59 is used if the same surgical procedure is carried out on multiple sites (for instance, removing lesions on various parts of the body through separate incisions). On the other hand, modifier 51 is required to report multiple procedures such as endoscopy and colonoscopy that are performed together.

4.     Mistake #4: Errors in Medical Code Unbundling

Medical codes are bundled when they belong to a single billable procedure. For instance, a surgeon may make an incision before a surgery. If it is an incidental incision, the surgeon will be required to close the incision. A normal closure of the incision is also incidental because the incision was made incidentally. Therefore, codes for these need to be bundled as there is no need for separate billing. It is thus important to know which procedures can be bundled and which cannot.

5.      Mistake #5: Ignoring Editorial Comments in Reference Books

The editorial comments that accompany various sections of a CPT book are extremely important as they have answers to many troubling questions that a coder or biller may have. For instance, if you are wondering whether you should report/bill for a preliminary hospital service when admitting a pregnant woman in labour, you can simply find the answer in the introductory editorial comments of the CPT book’s maternity section! Simple! 

Transcription Tips and Tricks You Can’t Ignore!

Now that you are aware of some of the best productivity tips for medical transcriptionists, we hope they are being put to good use. Here are some more tips and tricks for smart professionals.

Get Comfy

Make sure that your work environment is peaceful and quiet and that you are comfortably seated…’coz bad seating may cost you and your employer terribly high.Avoid work-related repetitive stress injuries by practicing proper seating and positioning and through stretching exercises that relieve the wrist, forearm, fingers, and back.  It is also essential to keep your workplace quiet because transcription requires a great deal of concentration. Do not transcribe if there is a great deal of ambient noise around you. If your workplace has a high amount of office traffic and noise, you could consider talking to your supervisor about making suitable adjustments.

Leave the Mouse!

Yes! You’d wonder how you could possibly get rid of the desktop mouse. But it’s important to understand that shifting hands between the keyboard and mouse every now and then slows you down. Practice using keyboard shortcuts instead. There are a multitude of keyboard shortcuts for all possible actions that you perform with the mouse. These can be mastered in a jiffy.

Keyboard Shortcut
Delete button
Switch between windows and programs
Current window’s system menu
Close or quit a program
Close current window
Choose a function in the menu bar
ALT+underlined letter in menu

Take Shortcuts

Those who say there are no shortcuts to success don’t know where to find one! In transcription, you can increase your productivity by using abbreviations. Word processors have features in the spelling auto-correction options where you can mention short spellings for commonly used words such as ‘surgery’ or ‘examination’. You could set the short spelling as ‘sgr’ and ‘exn’ for instance and the word processing software will automatically expand the word every time you type the short form.

You could decide which short form to keep for each word and the word processor will automatically change the short form to the full form as you type. Make sure you identify commonly used words to store in the word processor.

In case of MsWord, click on the spell check button at the bottom of the document and then choose “AutoCorrect” – in the options that pop up, click on “AutoCorrect options…” – next, in the ‘AutoCorrect’ tab, you will find an option that says “Replace words as you type”, make sure this is checked. Here you can add the words that you’d like to be replaced with full forms as and when you type.

Tips and Tricks for Transcribers

This is the first Avontix blog and we hope you’ll find it as hip and happening as your workplace! Read on for tips and tricks that you can use during your wild rides through medical transcription assignments. If there is anything else you’d like us to cover, just let us know!

1. Stuck with a bad dictation? Make some adjustments.

We know some physicians could be so bad at dictations that you need to make special adjustments. In case you are stuck with a bad dictation and are finding it difficult to understand, try adjusting the tone of the transcriber to remove bass. In case the transcriber has a bass control, use it to remove bass as much as possible and voila, the words will appear clearer. This will however increase static noise. This could be adjusted by varying the playback speed. Sometimes, it helps if you let others listen to the unclear section and get their suggestions on it. You could also skip the section, move on and then come back to hear it again. Oftentimes, re-listening to an unclear section after a while makes it easier to understand.

2. Telling a bad dictator he’s bad!

You may find yourself pretty unfortunate when paired up with a dictator who is chronically bad. In such a case, it is helpful to let the dictator know how he can improve his dictation technique. You can simply provide some dictation tips and send these along with a very courteous note saying how he can minimize ambiguities in his dictation. You could also return the transcription by leaving blank spaces for all unclear passages or blanks. If a dictator reverts back saying that you aren’t skilled enough for the work, you could show him successful transcription assignments previously done (after making sure you exclude confidential information). This could help in making him understand and take responsibility for a clear dictation. It would also do a favour for others in your organization!

3. No guesses, dude!

It is your responsibility not to guess about what you hear in the dictation. If a particular dictation is not clear, and especially if it involves drug dosages, drug names, therapy details, etc., making inaccurate guesses would actually be life-threatening for the patient if the error goes unnoticed. The most ethical and safe approach to an unclear dictation is leaving blank spaces wherever required and bringing it to the notice of the dictating physician so he can verify and help you complete an error-free transcription.

We’ll be back with more tips and tricks! Until then, stay healthy, stay happy, and stay productive!

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