Avoid These Common Problems Revealed by Medical Coding Audits

Keep these perennial pitfalls in mind for your internal auditing.

The AAFP tells healthcare organizations keeping their error rate (the percentage of claims payers deny) below 5% is “desirable.”

Hitting that target is hard. One consultant and auditor, Jacqueline Thelian, told For the Record she’d seen “maybe five clients” reach 95% accuracy in 27 years.

Internal coding audits can help you bring your error rate down. Yes, they’re time-consuming and costly, but it’s better to find problems before third-party medical coding audits do so you can fix them.

Better yet? Prevent coding problems in the first place. Fewer errors mean not only increased compliance with coding guidelines (meaning less regulatory headache down the road), but also more accurate patient records (meaning they get better care) and greater revenue for the services you provide (meaning a healthier bottom line for your organization).

We developed MDCodePro to help busy practitioners like you achieve these goals. And we’re happy to point out additional helpful resources when we find them.

So we wanted to spotlight coding consultant, educator, and auditor Terry Fletcher’s four-part series for ICD10monitor earlier this summer, “Auditing Issues Uncovered in Physician Documentation.”

Fletcher has over three decades of experience in medical coding, including regional and national service to the AAPC. She even hosts her own medical coding podcast. She’s well qualified to discuss the problems medical coding audits bring to light.


Reading her catalog of common pitfalls would be a great first step toward developing a medical coding audit policy for your organization. Fletcher offers both high-level overviews of areas where practitioners and coders get into trouble and several specific traps to look out for (for example: Only physicians can document the HPI—never medical assistants). Although she’s a specialist in the ICD-10 diagnostic codes, virtually all her advice holds true when dealing with CPT® codes, too.

You’ll be glad you spent time reading Fletcher’s whole series. For now, here are just a few cautionary takeaways to remember as you plan your internal coding audits:

Resist the Temptation to Undercode Patient Visits

Hopefully, you already know deliberately downgrading codes in hopes of avoiding audits is more than a bad idea. It’s every bit as fraudulent as upcoding.

There’s no guarantee this misguided strategy even works. As Fletcher writes, “assigning codes lower than what is supported by the documentation . . . can be as much of an audit flag as coding all level 4’s and 5’s.”

When you use a sound, validated methodology such as MDCodePro’s, you don’t have to be afraid to claim higher codes when appropriate. You’ll have all the documentation you need, and sometimes more than enough, to back whatever CPT® code the visit’s complexity and risk demands.

Hold Your Medical Histories to High Standards

Fletcher mentions she’s heard some doctors recommend eliminating the history from charts. Last year, even CMS considered removing E/M documentation requirements for the history and exam and relying on medical decision-making (MDM) and time as determining criteria instead.

But she argues the history is vital in establishing medical necessity: “It can lay the groundwork for the physician’s ‘right’ to move forward with the exam and medical decision-making.”

Make comprehensive histories your professional habit. MDCodePro shows you how easily you can. When you document a comprehensive history for your patients, as you were taught in medical school, you’ll have a better understanding of their complexity and risk, and a firm foundation for assigning the corresponding CPT® code.

Use Electronic Medical Records’ Code Selection Software Sparingly

EMR systems’ tendency to make copy-paste mistakes too easy to commit is only one reason providers must proceed with caution. Fletcher points out many problems she’s seen in medical coding audits result from these systems’ code selection software.

Wrong information about codes, difficult user interfaces, and missing features (including an alarming inability to recognize conflicting information in the chart), coupled with clinicians’ ongoing unfamiliarity with CMS’ E/M documentation guidelines, leave EMR coding software an only partially reliable resource for choosing codes.

Instead of relying on flawed EMR code selection software that could leave you liable for mistakes, use an app dedicated to guiding you through the process step by step while teaching you the “why” behind the “what” of CPT® code assignment.

Ace Your Internal and Third-Party Coding Audits with MDCodePro’s Help

“CPT® and ICD-10 coding do become less risky when documentation is done properly,” Fletcher writes.

We agree. As important as internal audits are, strengthening your documentation skills is critical to heading off mistakes found during third-party audits. When you document patient visits more accurately and completely, you’ll code them more correctly.

MDCodePro trains you to do just that. Our video lectures streamline CMS documentation guidelines so you can easily build them into your daily professional routine, and our code generator uses the information you input (not data imported automatically from charts) to point you to each visit’s most accurate, compliant, and revenue-increasing code.

Find out your current coding challenges. Then let MDCodePro help you correct them so your next medical coding audit finds you giving better patient care and capturing more of the revenue you’ve earned. Start your MDCodePro subscription today.

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