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January 2014

Beware of Poor Coding Habits
By Susan Chapman
For The Record
Vol. 26 No. 1 P. 20

From complacency to placing too much faith in technology, experts say coders could potentially lapse into mediocrity.

It sounds straightforward: The medical coding system applies specific numeric values to all medical procedures, diagnoses, disease symptoms, unidentified conditions, drug reactions, surgeries and their complications, and other medical events. If only it were that simple, many coders lament.

All health care settings—physician offices, hospitals, skilled nursing home, and other medical facilities—employ ICD-9-CM and HCPCS, with ICD-9-CM procedure codes used to collect inpatient data and HCPCS utilized for outpatient procedures and physician services. Because hospital payments, physician reimbursement, medical data collection, quality review, and other assessments are based on these codes, accuracy is crucial.

Despite the vagaries of ICD-9 and the pending arrival of ICD-10, coders, like any other professionals, can get caught in a rut, a situation that may lead to the formulation of bad habits. While errors can happen even when coders are sharply focused on the work at hand, poor habits can emerge and create a potentially crippling ripple effect.

To help lessen the chances of this phenomenon occurring, experts identify areas where coders may not be diligent enough and where they may fall into the trap of assuming too much.

The Issues
Whether coders are working in a hospital setting or coding remotely, they occasionally develop a tendency to not dig deep enough into the medical record. “There are a couple of reasons coders can make these superficial errors,” says Cathy Brownfield, RHIA, CCS, vice president of operations at Trust Healthcare Consulting Services. “One is that they have gotten into the practice of simply skimming the record and coding accordingly. For example, the direct code for congestive heart failure [CHF] is 428.0. A coder will key that in, but the documentation actually says that the patient has systolic CHF. There is a separate code for that condition. The same holds true for hypertension. The coder can look at the record, see hypertension, and enter the code. However, deeper in the record, the physician has indicated that the patient presented with malignant hypertension, which is not the same and requires a different code.”

After a while, coders memorize basic codes and no longer need to rely on resources such as reference books and software programs for assistance. For example, Brownfield points outs the popularity of Encoder, a software program that essentially is a computerized book of codes. With Encoder and similar tools, such as AAPC Coder, the diagnosis can be entered into the program’s search engine to produce specific options from which coders can choose.

“Just like in all jobs, people can get comfortable,” Brownfield says. “They become efficient at what they do and fall into a routine. What can also happen in an inpatient setting is that coders succumb to the pressure of productivity demands. People are always pushing coders to meet quotas.”

To save time and increase their chances of meeting deadlines, coders will employ software programs and other resources. However, it could come at a price. “The drawback is that this practice paves the way for common and repeated coding errors,” Brownfield notes.

Heather Golfos, CPC, a coding department assistant manager at Physicians Professional Management, believes that while software applications may allow coders to find codes easily, programs can be flawed. “I would recommend that coders search for codes through the code book, even though it can be a time-consuming process,” she says.

Golfos says coding from memory also can lead to developing poor habits. “When you code from memory, you run the risk of writing down the wrong codes,” she says. “If someone has been coding from memory for a long time, she can forget the description of what the code is. For example, we may see 30 cataracts in records in one given day. Coders can write down the code over and over again. But then you get one patient who has something a little bit different, which would be a different code, and it gets coded incorrectly.”

Of late, some harried coders have begun to use Internet search engines to find codes in order to accelerate the coding process. “[The Internet] is a good way to begin a search, but I tell my coders to always check whatever they find against the code book,” Golfos says. “That said, if you’re not having any luck in that way, especially if you don’t know where to start, sometimes you have to go online and Google it to see what you get. That can lead you in the right direction, but it can’t be where your research ends. The code book is always the best source. The Internet can have a lot of information, but much of it can be completely inaccurate.”

Cheat sheets are another way coders can avoid having to research codes. However, these unofficial resources can become outdated or are not specific enough for the diagnosis, leading to potential errors. “It’s common for coders to create these,” Golfos says. “I’ve been in this business for more than a decade. I have one; my department has created one. When you spend 45 minutes looking for a code, you write it down. The danger is that you don’t write everything down that is associated with that code.”

Inpatient coders especially are prone to the stresses associated with meeting productivity goals. As a result of these demands, they may shy away from using official resources and spend less time reviewing all documentation. Brownfield says inpatient coders may rely solely on physician dictation and ignore the associated notes. In addition, coders can receive information from various sources. In a hospital setting, because some documentation cannot be used for coding until the physician signs off on it, coders make due with what immediately is available. “These can be pretty troubling habits,” Brownfield says. “Coders are trying to pick up the pace by turning to quick resources and looking at the most obvious things. Very often, they leave off important secondary diagnoses.”

Golfos concurs: “Essentially, whether you’re coding for cataracts, hypertension, or any other diagnosis, if you’re not coding to the highest degree of specificity, it can easily affect reimbursement. If it’s an issue of medical necessity, you may use a less specific code when the payer requires a more specific code for accurate reimbursement.”

Failing to take advantage of coding clinics and other industry offerings is a big no-no in the eyes of Linda Lou Massey, CCS, CCS-P, outpatient clinical coding coordinator at Lancaster General Health in Pennsylvania, who says overlooking these offerings can lead to subpar performance. “The AHA [American Hospital Association] puts out quarterly online offerings. If coders do not keep up, they could very easily go down the wrong path,” she says.

Coders also should become involved in local associations to network with peers and obtain the latest information on rule changes. “They should stay involved with AHIMA, too,” Massey says. “Those with AAPC certifications can network through local chapter meetings, national events, and online forums.”

For remote coders, working in an unsupervised environment can lead to poor habits. Temptations such as checking e-mail and social media sites too frequently can spell trouble. “There are other distractions at home, too, that can pull your attention away from being effective,” Brownfield says. “If people have small children or pets at home or the television is often on, these things can take focus away from the job.”

Brownfield says discipline and structure help alleviate home distractions in many cases. But while she believes coders can be distracted working from home, Massey disagrees. “I haven’t found that to be true,” she says. “What I do find, however, is that some coders will have questions when working alone and don’t reach out to others to find answers. I always advise that if you have a question, send it out to everyone in your network. If it’s come up for you, then it’s probably something that has come up for other coders as well, and the answer would benefit everyone.”

Brownfield notes there are plenty of distractions in a hospital setting as well. “If you’re in a facility, getting caught up in what is going on in the office—watercooler talk—can affect your accuracy,” she says. “Sometimes it’s not just gossip. Sometimes you’re the one always trying to help someone else who has questions. There is a balance between acting like a team player and getting your work done. As a coder, you need to be mindful of your dedicated time to concentrate and be wary of constant interruptions.”

Spotting Problems
Managers must be adept at identifying and addressing bad habits. Brownfield monitors remote staff for productivity decreases and tracks coders who fail to consistently meet goals. “When that happens, I work with those individuals to help them see where they are not being productive and help them address those issues,” she says. “Avoiding that kind of thing altogether is difficult without putting a keystroke recorder on the computer. Instead, I encourage people to be focused and offer recommendations as to how often they should look at their e-mail—perhaps only once per hour, for example—and to stay off social media during work time.”

Managers sometimes spot poor habits through patient feedback. For example, a patient receives a bill from a physician for care that ordinarily is covered by insurance. When the patient calls to find out why a bill has been issued, the insurance company reveals that the physician or facility has coded the incident or diagnosis incorrectly. Once the patient subsequently reaches out to the caregiver, a coding manager most likely will become involved to determine exactly where the error occurred.

Auditing is another useful tool for pointing out where coders may be drifting into dangerous territory. For example, if a coder is repeatedly inputting hypertension and not malignant hypertension, then managers can dig deeper into the issue to determine why the secondary diagnosis is being ignored and whether the documentation is being captured accurately. “We perform regular audits,” Golfos says. “If we find specific mistakes with codes that are used often, that could be an indicator of things happening that need to be addressed.”

Angelica Stephens, RHIT, CPC, CCS-P, COSC, CPC-H, coding/charge entry manager at New Mexico Orthopaedics, uses audits to determine whether the latest coding updates are working in the EMR. “I also keep an eye on how charges are coming through,” she says. “My random monthly audits give me the ability to address any issues that arise.”

The consequences of inaccurate coding depend on how the codes are used. While incorrect coding can sometimes affect patient care, more often the damage is done in terms of reimbursement. Research also can take it on the chin. For example, if a researcher is engaged in a study when a report is run, incorrect codes can skew the data, and important elements can be missed. If patient data are not specific, integrity is lost.

“With meaningful use, a lot of new programs are coming out that have to show an improvement of quality of care for certain items,” Brownfield says. “If you don’t have the right code in there, it could potentially affect that also.”

To stay sharp and avoid falling into routines, Massey recommends coders take part in the AHA’s coding clinic, programs offered by JustCoding.com, or any of the learning platforms designed by AHIMA and AAPC. “Education is the key. Coders should take every opportunity to read, read, and read,” she says. “State and local health information chapters also have educational webinar and coding roundtables that can serve as a hedge against developing and proliferating bad habits. Coders should be taking the quizzes from Coding Clinic and JustCoding.com to help enrich their education. This can be done in a team setting or on your own.”

In the tests, coders are presented with specific scenarios, such as that of a patient with a history of polycystic kidney disease who has undergone a kidney transplant without the original organs being removed. The coder then is asked to assign the proper ICD-9-CM diagnostic code for the situation. Massey and her team regularly take such quizzes and submit them for scoring to ensure they remain current. “We’ve also started coding huddles weekly or biweekly to go over interesting and complex cases,” she adds. “The huddles have been quite educational.”

There also are events such as coding roundtables during which peers can audit one another. This can create a form of positive peer pressure that encourages greater attention to detail and accuracy.

Stephens, who says EMRs can complicate the coding process, believes new software implementations typically carry new sorts of problems. To help avoid pitfalls, she says managers must instill an inquisitive mindset in all employees and invest time in training, developing, and coaching staff.

“EMRs are programmed by humans, and they only have certain memory or capacity to store data,” she says. “A couple of years ago, I remember, while implementing and embracing a coding software, for some reason every MRI of the brain was coded with a pregnancy code due to a lack of common sense, if I may say. The coding software could not pick up the right code in spite of the accuracy of the documentation. We had to retrain the physicians to give us a different term to avoid confusing the coding application.”

In general, experts agree that it is sound practice to avoid coding from memory and to regularly review coding guidelines, particularly as the changeover to ICD-10-CM approaches. Do that and there’s a good chance bad habits won’t have the opportunity to gain a foothold.

— Susan Chapman is a Los Angeles-based writer.