Healthcare coding can prove quite challenging and frustrating, as coders must make sure to continuously update themselves on the latest codes and terms needed to achieve their desired outcome. Renee Dowling, a compliance auditor at the California-based Sansum Clinic, LLC, notes the difficulty in accurately employing both current procedural terminology (CPT) and International Classification of Diseases, Tenth Revision (ICD-10) codes.

One particularly challenging area, according to Dowling, is ensuring that ICD-10 coding is done to the highest level of specificity. For instance, coders should make sure that each code on their ICD-10 contains the necessary number of digits, as this type of misinformation could result in a denied claim. Dowling encourages coders to use physicians’ medical reports as a means of providing substantial amounts of detail and to take accurate notes. It is also crucial for coders to familiarize themselves with both procedural and diagnostic medical terminology. In certain situations, however, coder submissions are not applied to the highest level to no fault of their own. For instance, consider cases when a provider provided information that was too general to warrant either a diagnosis or a procedure.

In a perfect world, all coders would be dealing with easily accessible providers, but this is not a reality. If a coder is struggling to make sense of a specific claim, providers will not always be able to assist. As such, clarifying a coding issue may not be a quick-fix situation. Dowling notes that if time is of the essence, and a coder must submit information that was not looked over by the provider, less detailed or unspecified codes may have to be billed. Unfortunately, this could result in rejected claims.

According to Dowling, failure to use current or updated code sets could also lead to denials. The World Health Organization for ICD-10, the Centers for Medicare & Medicaid Services for Healthcare Common Procedure Coding System (HCPCS), and the American Medical Association for CPT annually update the three main medical coding manuals. Coders are responsible for updating themselves on any new, changed, or eliminated codes, and the onus is on them to correctly apply those codes.

When coders separately code procedures that are typically bundled together, the process is known as unbundling. According to Dowling, unbundling, similar to upcoding, involves false reporting. This could be misconstrued as a strategic move by the coder to seek a higher payout on the provider’s behalf. In an effort to avoid unbundling, Dowling suggests that coders check the National Correct Coding Initiative to familiarize themselves with CPT code descriptions and to determine which CPT codes can be billed together. Coders must also take care to avoid undercoding. Dowling notes that the former omits all work provided by the physician, often due to oversight. However, some organizations undercode to sidestep an audit—a tactic that could lead to significant revenue loss.