Why you need to stop downcoding

Downcoding doesn’t bring benefits to your practice.

When it comes to insurance coding, hitting the target, spot on, is the key to successful reimbursement. Easy? Not always, say analysts.

Downcoding is the practice of reporting a code to a procedure that yields a lower reimbursement rate than the correct code would. It was once the domain only of third party payers to downcode, but physicians have occasionally been audited for undercoding their own documentation.

Why do you downcode?

Why would they do that? It may stem from an office assistant’s inability to read the doctor’s SOAP notes accurately. Or it may be done intentionally to “help” patients who cannot afford the fee for the more expensive procedure. The practitioner may feel that by undercoding, their claims are more likely to be paid than more expensive procedures.

Coding consequences

Undercoding is an unwise course of action that can backfire. For example, practitioners who undercode might be more likely for an audit if their services are consistently below average. Or, if the patient needs more extensive treatment later, the practitioner could be questioned—even sued for malpractice—for not documenting accurate details of the treatments in a complicated condition.

This, unfortunately, happened to an Arizona chiropractor who failed to document properly the treatments of a diabetic patient.1

Even when intentions are noble, it’s in your best interest not to assume guardianship for your patients’ finances. Honesty is always the best policy.

And if the downcoding happens through the third party source? Theresa Wray suggests that you appeal that decision, every single time. She reports that practices lose about nine percent per annum due to downcoding.2

Accuracy matters

If you are billing and coding accurately, you earned every penny of that reimbursement. It is unjust if you are not paid what you deserve. It may add more details to gather and follow up on than you want or need in your busy practice, but you owe it to yourself to defend your earnings.

Option to simplify with an EHR system

Some providers have simplified their coding through electronic health records (EHR) software. Many versions are available, and some may better suit your practice than others. These computer-based, and sometimes cloud-based, EHR programs can save labor costs, paper, and eliminate coding errors due to hurried handwriting.

If you decide to research software programs for your practice, evaluate online reviews, ask a lot of questions, and most importantly, get training for everyone who will be using it. It can only help you and be accurate if the users know what they’re doing.

Know what you’re getting into

As employer-provided health care moves into place nationwide, chiropractors may want to gear up now for what may result in an influx of new patients in 2016. Concentrate on coding compliance, and eliminate that conundrum from your life.

Sunny Cook is an Asheville, North Carolina, freelance writer and copy editor with an extensive background in natural health. She invites you to connect with her on LinkedIn.

References

1 Schetchikova, Nataliya. “Documentation with EHR–Easier, Faster, Better?” http://www.acatoday.org/content_css.cfm?CID=4241. American Chiropractic Association. Published January 2011. Accessed October 2015.

2 Wray, Theresa. “Downcoding Explained: Part 1.” http://www.synergyconsultingsvc.com/downcoding-explained-part-1/. Synergy Consulting Services. Published January 2015. Accessed October 2015.