Most Common Medical Coding Questions in 2024: Insights from the YES Experts

Most Common Medical Coding Questions in 2024: Insights from the YES Experts

To shed light on some of the most pressing challenges faced by healthcare organizations in 2024, I sat down with the experts at YES HIM Consulting, who shared the most common medical coding questions they’ve encountered this year. From clarifications on DRG assignments to navigating NCCI edits, their insights provide actionable advice and emerging trends for coders, managers, and healthcare organizations seeking to enhance accuracy and compliance in their coding processes.

Question 1: What types of coding-related questions have you and your teams encountered most frequently this year? What were the answers to these questions?

Sarah Collins Hill, ProFee Coder/Auditor Lead, says the ProFee Coding and Auditing Services Team has most frequently been asked whether providers can bill breast capsulectomy with tissue expander replacement (CPT codes 11970/19390).

“Unfortunately, the NCCI edits bundle CPT 11970 (replacement of tissue expander with permanent implant) into 19370 (revision of peri-implant capsule, breast, including capsulotomy, capsulorrhaphy, and/or partial capsulectomy),” she explains. “Coding Clinic for HCPCS 1Q 2021 addresses this on pages 11 & 12, where they state, ‘Please be aware that there is an NCCI edit that prevents the reporting of CPT code 11970 with code 19370. Therefore, you may wish to contact your payer(s) for reporting requirements as policies may vary.’”

Additionally, the ProFee Coding and Auditing Services Team was regularly asked about assigning CPT code 47563 for the use of ICG Firefly during a cholecystectomy.

“In 2Q 2023, the Coding Clinic for HCPCS said that ‘Visualization of structures with ICG to aid with dissection is not analogous to an intraoperative cholangiogram. Therefore, assign CPT code 47562, Laparoscopy, surgical; cholecystectomy, for the laparoscopic cholecystectomy,’” Collins Hill says. “We do not recommend 47563 for this case, as the Firefly technology was used to visualize the common bile duct to aid in dissection.” She noted that our consultants sent this question to the AMA CPT Knowledge Base for guidance, and we are still awaiting a response as of November 19, 2024.

“We provided CloudMed education to our clients and our coding teams,” Amy Davis, Director, Inpatient Coding and DRG Validation Services, says. “This year, we provided education on MS-DRGs 871 (Septicemia or Severe Sepsis without MV > 96 hours with MCC) and 872 (Septicemia or Severe Sepsis without MV > 96 hours without MCC) where procedural codes impact the MS-DRG assignment.”

Davis and her team also received inquiries about MS-DRGs 682 (Renal Failure with MCC) and 683 (Renal Failure with CC) changes due to ICD-10-CM code T86.19. Education was also provided on cardiac catheterization coding, which changed MS-DRG 291 (Heart Failure and Shock with MCC) to 286 (Circulatory Disorders except AMI with Cardiac Catheterization with MCC).

This year, our Inpatient Coding and DRG Validation Services Team was busy educating clients on heart failure and other severe conditions. “We provided education for typical scenarios for MS-DRG 603 (Cellulitis without MCC), 291 (Heart Failure and Shock with MCC), 871 (Septicemia or Severe Sepsis without MV > 96 hours with MCC), 308 (Cardiac Arrhythmia and Conduction Disorders with MCC) and 292 (Heart Failure and Shock with CC),” Davis shares.

Elizabeth Kelly, Director, Auditing Services, and her team received the most questions on Spinal MS-DRGs (formerly MS-DRG 460) and Sepsis MS-DRG this year. “Some of our most frequent coding-related questions involved the selection of principal diagnosis for ICD-10-CM and body part selection for ICD-10-PCS,” Kelly explains. “We review and validate the procedure codes are correct. PCS coding is still a challenge to many coders.”

She continues, “In response, our team will perform an in-depth review of the entire medical record and apply any applicable coding guidelines and/or Coding Clinic recommendations.”

Kelly and her team often refer to our highly skilled team members for second opinions as our staff come from various work backgrounds and have a vast set of unique skills.

“We also meet monthly during our Case Study Reviews to discuss various scenarios we have come across and to ensure that our entire team is consistent with any feedback we provide to both our internal and external customers,” Kelly says.

Monthly educational reviews are essential to Davis and her team, too. “Our coding team meets for our monthly coding roundtable topics, and we have also shared this information with our clients,” Davis explains. “The topics included Acute Respiratory Failure vs COPD as the principal diagnosis, GI dissection, compliant coding query guidelines and scenarios, and abortion coding.”

Question 2: Are there specific areas of coding that generate more questions from clients or team members?

Davis and Kelly confirm that DRG validation and the selection of principal diagnosis rank high among the total number of Inpatient coding questions they receive. According to Kelly, Outpatient coders ask mostly about coding guidelines and specific CPT codes.

On the ProFee coding side, Kelly says more of the questions come from newer coders trying to learn a new specialty. “They are asking a lot of questions pertaining to the specialty that involves some harder surgery cases,” she explains. “Sometimes they see a new surgery or service that their provider has not done before and need help. These services involve plastic surgery, vascular surgery, transplant surgery, cardiology, and general surgery.”

Question 3: Have you noticed any emerging trends or patterns in the types of coding questions received this year? How does your team support clients during these challenges?

“Principal diagnosis selection continues to be an emerging trend this year,” Davis says. “The complexity of cases has also generated questions about coding operative procedures using ICD-10-PCS coding.” She confirms that the source of these questions derives from the need for education to ensure coding and facility guidelines are being followed for coding accuracy.

Kelly pinpoints that the trends in coding questions they receive are based on new codes and guidelines. She lists the recent change in MS-DRG assignment for spinal fusions as one example. “Trends are also based on specific client needs such as review of COPD vs acute respiratory failure as principal,” Kelly says.
Regarding emerging trends, the first thing that comes to Collins Hill’s mind are questions regarding the surgical approach (i.e., open vs. laparoscopic vs. endoscopic vs. percutaneous). “CPT codes are assigned based on the approach, but the code doesn’t always match what the surgeon did,” she says. “We may have a code for a procedure if it was performed via an open approach, but the surgeon used laparoscopy. In those cases, we advise using an unlisted code.”

Collins Hill and her team members have noticed that the complexity of the questions has increased. “This tells us that the coders we work with have a thorough understanding of surgical basics and are moving into more complicated cases,” she explains. “Makes for some enjoyable research!”

Our ProFee consultants believe new technology significantly contributes to the types of questions they receive from clients. Collins Hill says, “The CPT codes don’t always keep up with the procedures being performed.”

She continues, “Another factor is conflicting guidance from CPT guidelines versus NCCI guidelines. It can be frustrating when CPT gives coding instructions, but the NCCI and other payer edits directly oppose those instructions.” Kelly concurs that coders often have trouble with NCCI edits and what is already included in the surgical service provider.

Collins Hill also noted that they’re fielding more questions directly from surgeons, and she points to an increased level of physician engagement. “The providers pay close attention to their coding and reimbursement as Medicare payment rates continue to decrease,” she explains. “We appreciate the input from the physicians and always learn a lot from them.”

Our coding and auditing teams at YES excel at addressing complex coding questions. Jennifer Dilley, Director, ProFee Coding and Auditing Services, says, “We do thorough research using resources like the CPT Knowledge Base, CPT Assistant, and other coding guidelines to ensure accurate and up-to-date information.”

In addition to referring to professional resources, our consultants rely on each other and pull from their collaborative expertise to solve challenging encounters. “Internally, we consult with our diverse team of coding and compliance experts to provide well-rounded and practical solutions tailored to our client’s unique needs,” Dilley explains.

Our consultants always strive to answer any client’s question completely. “Our audit team meets to discuss complex cases and provide feedback to clients,” Kelly says. “In some cases, we submit questions to the Coding Clinic.” Another bonus of working with YES is that we offer a question queue to our clients, where they can post specific inquiries for further information.

“Our team provides expertise on challenging coding issues,” Davis says. “Healthcare organizations can stay on top of trends by providing in-depth training and education utilizing current medical coding resources.”

Ultimately, communication is key to addressing emerging trends or challenges in the healthcare sphere. Dilley says, “Prioritizing timely and clear communication minimizes disruptions to our client’s workflows.”

Question 4: Any final advice for medical coders or coding managers to stay updated and reduce uncertainties in their processes?

Coding guidelines and regulations frequently undergo updates, so our directors advise coders to invest in continuous education so they can stay ahead of those changes. Regularly review new coding guidelines, code updates, and payer-specific policies. Don’t forget to utilize all the industry coding resources, such as the official coding guidelines, Coding Clinic articles, and CPT Assistant advice, for guidance. “Allocate dedicated time for education and professional development,” Dilley says.

Kelly advises that if your facility is performing new procedures or using cutting-edge technology, research how to properly document and report these new additions. Ensure you have a current coding policy in place to assist coding staff with abstracting and coding.

Creating a streamlined coding process requires coding technology and cross-departmental collaboration. Dilley suggests coding teams partner with other internal departments, such as billing and clinical teams, to ensure consistent processes and a smooth revenue cycle. And when your internal teams need additional assistance, she recommends utilizing trusted external consultants. “Maintain a relationship with reliable external experts or consultants for guidance on challenging scenarios and to validate internal processes,” she says.

Don’t forget to schedule regular coding reviews. “It’s important to audit and trend your employees,” Davis says. “Hold them accountable to an established quality standard for coding/DRG assignment accuracy.”
Kelly agrees, “Ongoing audits is the best approach to keep up with coding changes, new guidelines, new references, and new edits.”

Our Experts Can Provide Hands-On Assistance

Navigating the intricacies of medical coding requires expertise, collaboration, and a commitment to continuous learning. YES empowers healthcare providers by offering comprehensive services in coding, auditing, education, and consulting. Whether addressing complex coding challenges, conducting thorough audits, or providing tailored training programs, our team is dedicated to helping you achieve coding accuracy, compliance, and operational efficiency. Partner with YES to stay ahead of industry trends and ensure excellence in your healthcare operations.