Updated on: November 28, 2016

An Auditor’s Observations on ICD-10 Audits and Compliance

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Original story posted on: April 25, 2016
We are nearly six months into ICD-10 and more coding reviews and audits are underway, which is a good thing. There are close to 30 times more procedure codes and five times more diagnosis codes in ICD-10-CM/PCS, compared to ICD-9-CM.

In addition, thousands of new and revised codes will continue to emerge, and these reviews and audits will continue to prove valuable in assisting with identifying more patterns, trends, and best practices associated with documentation, correct code capture, productivity, accuracy, training, education, compliance, query practices, data analysis, and many more areas.

With the agreement made between the Centers for Medicare & Medicaid Services (CMS) and the American Medical Association (AMA) back in March of last year, no physician claims submitted to Medicare now can be denied solely due to the “use of an unspecified or inaccurate subcode.”  Even though this agreement allows for some time for providers to master the more complex ICD-10 code system, healthcare and coding professionals need to be prepared and stay abreast of compliance and regulatory updates.

CMS, the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG), the Health Insurance Portability and Accountability Act (HIPAA), and the Office of Statewide Health Planning and Development (OSHPD) in the State of California are just some of the regulatory agencies and legislation that provide updates and guidance on coding accuracy, compliance, expectations, and best practices. One of the top priorities for the federal government is eliminating healthcare fraud and abuse, as we all know. In performing audits or assessments on large volumes of records, there are numerous patterns and trends that have surfaced that are worth sharing, based on some observations. 

Some of the trends I’ve identified through my auditing work are incorrect ICD-10 codes being based on insufficient clinical documentation, missed codes despite supporting documentation being present within the medical record, insufficient or inconsistent documentation to support code assignment, and lack of supporting documentation. Also, I’ve seen that some portions of the official guidelines have not been fully understood and the American Hospital Association (AHA) Coding Clinic on ICD-10-CM/PCS had not been fully read through. Having both an internal and external audit review not only would be beneficial for organizations, but it is also a best practice. The frequency of the audits/reviews can be monthly, quarterly, or annually, although monthly reviews during these initial six to eight months can really provide insight and alleviate future incorrect code assignments. Focused reviews should also include validation using concurrent and pre-bill audits surrounding inpatient MS-DRGs, the present-on-admission (POA) status indicator, severity of illness, risk of mortality, medical necessity, and discharge disposition, just to name a few.

One common ICD-10-PCS error often found is the incorrect code assignment of “open” procedures versus a “percutaneous” or “percutaneous endoscopic” approach. It is a misconception that once “incision” is documented, a case is automatically coded to “open.” “Open” is the cutting through the skin or mucous membrane and any other body layers necessary to expose the site of the procedure, while “percutaneous” is the entry by puncture or minor incision or instrumentation through the skin or mucous membrane and/or any other body layers necessary to reach the site of the procedure. Both approaches may involve incision, and careful review of the documentation in the operative report is needed. If documentation is not clear, there is the option to query the provider. For example, an incision and drainage may be coded to “open” if further incision and exploration are performed.  

Non-excisional and excisional debridement coding is also a topic of interest for ICD-10-PCS. According to the AHA Coding Clinic published in the first quarter of 2004, excisional debridement involves “cutting outside or beyond the wound margin in removing devitalized tissue.” Many times “excisional” debridement is coded when the documentation in the procedure note only supports “non-excisional” debridement. It is also important to review what sharp instruments were used and how they were used in the procedure.  

For example, in California, there are specific mandates pertaining to reporting external cause codes and HIV/AIDS. External cause codes are required for OSHPD data reporting in California, which impacts coding and documentation specificity, especially in the ED setting. Also in California, only confirmed AIDS (B20) is coded, and HIV infection status (Z21) is not reported at all, unlike in other states.

The ICD-10-CM code for P08.21, post-term infant, is also often missed, marking another common finding in my audits. Coding professionals questioned if it was appropriate to capture this code solely based on the newborn’s gestational age, with no other documentation in the medical record. Would it be appropriate to code “post-term infant” when coding guidelines state to “code all clinically significant conditions if it requires clinical evaluation; or therapeutic treatment; or diagnostic procedures; or extended length of stay; or increased nursing care and/or monitoring; or has implications for future healthcare needs?” The answer is yes. According to the AHA Coding Clinicpublished in the second quarter of 2006, post-term infant and prolonged gestation of infant may be assigned based only on the gestational age of the newborn. A specific condition or disorder does not have to be associated with the longer gestational period to use these codes. For more information on applying past issues of the AHA Coding Clinic during evaluation of issues associated with ICD-10, please refer to pages 20-21 of the edition published during the fourth quarter of 2015.

Each coding professional must familiarize himself with the ICD-10-CM/PCS Official Guidelines on Coding and Reporting, additional resources such as AHA Coding Clinic (on ICD-9-CM, ICD-10-CM/PCS, and HCPCS), the American Health Information Management Association (AHIMA) Practice Brief from 2013 on Achieving a Compliant Query Process, and the AHIMA Code of Ethics, to start. Each state also may have its own coding-specific rules that each coding professional must apply. 

Having coding audits conducted on a regular basis to ensure coding accuracy and compliance must be part of every company, practice, and organizational strategic plan. Our ICD-10 journey has just begun, and we are all learning together.

Let’s all stay involved and work collaboratively in promoting high standards of health information management (HIM) and coding practice. In the end, all the quality data will promote and help achieve better health for all patients.
Disclaimer: Every reasonable effort was made to ensure the accuracy of this information at the time it was published. However, due to the nature of industry changes over time we cannot guarantee its validity after the year it was published.
Victoria M. Hernandez, RHIA, CDIP, CCS, AHIMA-Approved ICD-10-CM/PCS Trainer

Victoria is a coding professional with 20 years of experience in healthcare. She is the founder of Integrity Coding Solutions.

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