Coding Tips

Common Physician Documentation and Billing Errors

1. No documentation for service billed
2. Missing signatures
3. Assigning the same level of service
4. Billing for a consultation instead of an office visit
5. Using invalid codes from old coding resources
6. Unbundling procedure codes
7. Misinterpreting abbreviations
8. Not listing the chief complaint
9. Billing of service included in the global fee as a separate professional fee
10. Assigning inappropriate modifier

Physician Documentation Tips

1. Be specific: Coders are not permitted to base codes on lab reports
2. Specify definitive principal diagnosis
3. List all complications and comorbidities that affect treatment received on
extended length of stays
4. Specify acute or chronic
5. Specify adverse effects of a drug or a treatment: Specify the nature of the
effect and treatment
6. Specify complication cause ex: postoperative, mechanical failure, drug induced
7. Use qualifiers for secondary diagnosis "due to", "secondary to", "with"
8. Specify if heart or renal disease is "due to hypertension"
9. List "late effect" and nature of residual illness or injury
10. Document legibly

Specifying Diagnosis Tips

1. Anemia: What type?
2. Asthma: Was it status asthmaticus?
3. Burns: What degree?
4. Debridement: Was it excisional or non-excisional?
5. Diabetes: What type?
6. Fracture: Specify the type and site
7. Infections: What organism?
8. Hypertension: Benign or malignant?
9. Neoplasm: Primary site or metastasis?
10. Coronary Artery Disease: Was it the cause of the angina?

Documentation and Coding Resources

ICD-9 Coding Resources
• Coding Educational Resource Web Guide