Seven Steps for Effective Coding: Avoid Claim Denials

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By: Vilmar Trinta Negrón | Interview by: Lilybeth Rivera

Accurate coding ensures that patients receive the appropriate treatment plans for managing their health conditions, avoids claim denials or reduced payments, and influences the premiums that Medicaid assigns to its members.

To achieve proper coding, healthcare providers must document and substantiate each diagnosis following the clinical documentation guidelines provided by ICD-10 (International Classification of Diseases, 10th Revision) and regulatory health agencies.

There are two classifications of codes: service codes and diagnostic codes. Service codes describe the procedures and services performed in healthcare, such as consultations, treatments, and surgeries, while diagnostic coding focuses on the conditions or symptoms the patient presents. The most commonly used service codes are CPT (Current Procedural Terminology) and HCPCS (Healthcare Common Procedure Coding System), whereas ICD-10-CM (International Classification of Diseases, 10th Revision, Clinical Modification) codes are used to describe diagnoses.

What Are the Recommendations for Effective Coding? Lilybeth Rivera García, Coding and Premium Management Director at Provider Network Solutions, shared seven steps for accurate coding:

1. Review Medical Documentation: Information about diagnoses and procedures must be clear and detailed to assign the correct codes.
2. Identify the Reason for the Encounter.
3. Use the Alphabetical Index in ICD-10-CM to Choose the Code. Then consult the tabular list.
4. Confirm the Diagnosis in the Tabular List, as the code may have additional instructions (e.g., “use additional code”). Pay attention to additional characters—some codes require seven characters for more specific coding. Read all instructions in the tabular list.
5. Consult Updated Official Guidelines.
6. Confirm and Assign the Code.
7. Repeat the Steps for Additional Diagnoses.

Rivera also provided examples of commonly mis-coded diagnoses, noting that higher subcategories lead to higher premiums due to increased costs associated with managing the condition.

One example is hypertension. If a chronic condition like hypertension is incorrectly coded, the implications for medical care can vary based on the complexity of the case. For instance, benign hypertension (code I10) in the CDPS-RX payment model implemented by Vital falls under the cardiovascular category in the extra low subcategory. In contrast, hypertension accompanied by heart failure (code I11.0) is classified in the same category but belongs to the medium subcategory. This means the premium associated with code I11.0 will be higher than that of code I10.

Another example is chronic kidney disease (CKD). If the biller submits a claim indicating the patient has CKD stage 5 (N18.5) but does not bill for dialysis dependency (Z99.5) because they consider it obvious or because the physician did not document it, the patient will receive a lower premium than they are entitled to.

Both cases highlight the importance of accurate coding to ensure patients receive appropriate premiums for managing their medical conditions.

While claims can be corrected after submission, this process is slower and more complex because it involves:

“This unit is backed by advanced technology, allowing for streamlined processes and gap detection. This optimizes the quality of coding and documentation, thus ensuring the best health services for beneficiaries,” added Rivera.

She also announced that the digital platform eCARE (electronic Comprehensive Annual Risk Evaluation) it is now available. This practical and efficient clinical documentation tool designed for the annual assessment of beneficiaries of the Plan de Salud Menonita Vital will enable accurate capture of health condition diagnoses, aligning with the new CDPS-Rx payment model (Chronic Illness and Disability Payment System with Prescription). This predictive model combines diagnostic data (ICD-10 codes) and pharmacy data (NDC codes) to assess patient health risk.

Note: Jahaira Rivera from CRC and billing specialists Amarilys López and Bárbara Hernández collaborated on this article.

This post is also available in: Español (Spanish)