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Tracy Goglio Staff Corner- # 3 of 4

What are common mistakes you see that lead to down codes? How can these errors be avoided?

Common documentation mistakes we see from providers is with ROS, where Providers are not documenting pertinent negatives and positives when utilizing “all other systems reviewed and negative” statement. A 99285 requires 10 ROS systems, or at least two pertinent positives/negatives plus the all other systems reviewed – Elimination of erroneous ROS auto statements in the EMR and giving providers feedback and education on requirements, should reduce downcodes. Another common downcode is with HPI. Not documenting 4 HPI elements is one of the costliest documentation errors. 99285 requires 4 elements and if only 3 can be obtained, that drops the EM to 99283. Providers should receive feedback and education on formulating an extended HPI.

As for coders, finding 4 HPI elements can sometimes present a challenge, especially for psych patients. Also knowing when it is appropriate to infer the CMS history caveat, when the Patient’s clinical condition precludes obtaining a history from the patient or other source. Another area is PFSH – this can harbor in the HPI, so coders should be checking the HPI for past, family, or social history. Providing coders consistent feedback and job aids, will help in eliminating erroneous downcodes in all areas.

Tracy Goglio, CPC, CEDC
ED Coding Manger

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