Whether upcoding or downcoding, both can potentially put you at risk and both are undesirable for a well managed practice. Upcoding claims will get the attention of payers and instigate an audit. This can lead to takebacks, and a compliance risk for the practice. Downcoding is a common occurrence when providers don’t have a properly setup EHR or are documenting with traditional methods and not gathering the required information.
Coders are left to base their decisions off of what has been provided and if the content and detail is lack downcoding will likely result. Both downcoding and upcoding can be unintentional and a lack of education and understanding of the service, procedure, or diagnosis and how it relates to the optimal level of specificity may result.
There are multiple factors that can necessitate a higher level of coding for evaluation and management coding for example the subspecialties, practice demographics, patient acuity statistics, administrative adjustments and denied claims analysis
Periodic chart and coding audits can help prevent upcoding and downcoding. Typically a provider will have 10-20 charts audited at least one to two times per year. An internal reviewer or external reviewer can be utilized. The information is valuable only when it is shared with coding staff and providers.
Documentation and coding audits should follow a structured methodology to identify existing coding and documentation issues that may affect practice revenues and/or compliance risks. The review should encompass documentation, coding, and billing. Methodology should also be mapped out and consistent to identify over-coded or under-coded Evaluation and Management Services. Missing or incomplete information can significantly impact an audit. Having all of the information gathered for each visit is critical to ensuring a fair audit.
Audit outcomes should be organized in an easy to read chart form for provider review as well and feedback on the documentation review findings. Including the copies of the charts reviewed allow a deeper look when deemed necessary. Providing this level of detail will create opportunities for change rather than additional confusion about how to chart and code claims.
Through this process a reduction in overcoding and undercoding can also be realized. With ICD-10 relatively recent many providers, coders and billers are settling in to new habits, good or bad. Conducting a coding review can reduce the chances of payer audits and takebacks while increasing the overall compliance for the practice in 2016.