Billing, Coding, Auditing, Revenue Cycle Support by BCA

Avoiding Coding & Documentation Pitfalls as the Year Wraps Up

As the year comes to a close, practices often face increased scrutiny from audits, payers, and risk adjustment programs. Week 10 of our series focuses on common coding and documentation pitfalls and practical strategies to avoid them, ensuring your practice stays compliant and maximizes reimbursement.

Common Pitfalls to Watch

  1. Vague or Non-Specific Diagnoses
    • Example: Using “diabetes mellitus, unspecified” instead of specifying type and complications.
    • Impact: Downcoding, denied claims, and reduced HCC capture.
  2. Incomplete Documentation for Telehealth
    • Missing patient location, mode of communication, or consent.
    • Impact: Non-compliance with payer requirements and risk of denied claims.
  3. Failure to Capture Comorbidities
    • Example: Omitting obesity, CKD, or tobacco use when present.
    • Impact: Lower HCC scores and decreased risk-adjusted reimbursement.
  4. Incorrect or Outdated Codes
    • Using deleted or revised ICD-10-CM codes.
    • Impact: Claim denials or audit issues.
  5. Time & Service Misalignment
    • Billing E/M or telehealth codes without corresponding documentation of time, MDM, or counseling.
    • Impact: Compliance risk and underpayment.

Strategies to Avoid Pitfalls

  1. Audit High-Volume Codes
    • Identify frequently billed services and review documentation for accuracy and specificity.
  2. Educate Clinicians & Staff
    • Provide quick refreshers on new 2026 ICD-10-CM codes, HCC updates, and telehealth documentation requirements.
  3. Use EHR Tools & Templates
    • Smart phrases, prompts, and templates ensure all required elements are captured consistently.
  4. Verify Comorbidities & Complications
    • Cross-check problem lists, lab results, and patient history to ensure all chronic conditions are coded accurately.
  5. Stay Ahead of Payer Updates
    • Monitor CMS and commercial payer rules to ensure coding and documentation meet the latest standards.

Looking Ahead

Next week, we’ll discuss integrating telehealth, ICD-10, and HCC updates into your daily workflows, helping your practice operationalize all the changes we’ve covered this fall.

By proactively addressing these common pitfalls, your practice can protect revenue, maintain compliance, and finish the year strong.Sign up for our mailing list and follow along for more insights. http://eepurl.com/ihek1L