Make Software Coding Edits a Friend, Not Foe

“Clean” claims are only as accurate as your trained coders.

By Angela Clements, CPC, CEMC, COSC

Software coding edits can be beneficial for a physician office or they can be harmful—it all depends on the end user. From my experience, the pros of software coding edits outweigh the cons.

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Pros: Software coding edits provide practices with opportunities for education and a safeguard against claims denial. As a coder reads the documentation to verify the edit, he or she may find areas where physician education would improve coding (e.g., documentation lacks supporting co-morbidities that affect the visit, information required in the procedure note is missing, or documentation doesn’t match coding level). Having a coder who is knowledgeable and capable of providing physician education is important; the coder can keep up with coding changes and requirements, while the physician can focus on patient care.

Cons: Edits are sometimes incorrect due to logic errors or untimely updates. A coder should never correct coding based on a software coding edit alone.

Best practices: Always review documentation prior to changing, deleting, or adding codes and modifiers to a claim. Documentation must support the coding of a service or procedure and modifier use.

Money Recouped

Failing to review documentation and simply following the guidance of an edit may result in insurance reimbursement, but you’re upping the ante for how often a payer sends your practice a request for repayment of an incorrectly reimbursed claim after a review of the charges and documentation. To give you an idea of what can happen, depending on who’s reviewing the claim, consider the following example:

An office visit (99213 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity) is coded on the same day as a joint injection of Kenalog into the knee (20610 Arthrocentesis, aspiration and/or injection; major joint or bursa (eg, shoulder, hip, knee joint, subacromial bursa) and J3301 Injection, triamcinolone acetonide, not otherwise specified, 10 mg). The application generates an edit, indicating that the office visit should be appended with modifier 25 Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service.

— Coder A appends modifier 25 to the charge, the edit resolves, and the claim is submitted to the insurance company, processed, and paid.

— Coder B reviews the documentation and notices the physician documented, “Patient continues to have pain to the right knee and is returning to the office for a steroid injection.” He also documents the procedure note to support the injection. Upon review of the previous office note, Coder B notices the physician documented that the patient should return for a steroid injection if the pain did not lessen with medication. With this greater understanding of the situation, Coder B removes the office visit from the claim, which resolves the edit. The claim is submitted to the insurance company, processed, and paid.

A year later, a recovery audit contractor (RAC) reviews the documentation. Coder A receives a letter stating the RAC is recouping money for the paid office visit. Why? Because Coder A did not review the documentation to ensure it supported the codes billed. The injection was ordered at the previous office visit, and the documentation for the service in question did not support an office visit as a separate and identifiable service; therefore, the office visit should not have been billed to the insurance company.

Claims Denials

The whole purpose of coding edits is to detect errors before a claim is submitted to the insurance company. The software does little good, however, if the errors it detects are ignored. An example of what may occur, depending on who’s reviewing the claim, follows:

The physician injects the fascia on a patient with plantar fasciitis. He captures code 20552 Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s) with 726.91 Exostosis of unspecified site. A coding edit rejects the claim because the diagnosis is inconsistent with the procedure.

— Coder A reviews the medical record (with tunnel vision) and verifies the diagnosis code. She notes the patient is diagnosed with plantar fasciitis. She documents on the account that the note is coded correctly and bypasses the edit. The claim is sent to the insurance company, processed, and denied. The coder reviews her notes and adjusts off the charge. The physician receives zero dollars for his work.

— Coder B reviews the medical record and discovers the physician injected the fascia, not a trigger point. She corrects the CPT® code to 20550 Injection(s); single tendon sheath, or ligament, aponeurosis (eg, plantar “fascia”). The edit resolves, the claim is submitted to the insurance company, and the physician is paid for his service.

Be Smarter Than the Software

It’s very important to use your coding skills, and not to rely solely on computer software to correct your claims. Coding edit software can help your practice submit “clean” claims—that is, claims without any red flags the payer’s coding edits will catch—but it isn’t capable of logical thinking. For example, coding edits cannot catch issues such as not documenting or coding to the highest level of diagnosis specificity, or lack of documentation. That’s your job.

Even software equipped with an evaluation and management (E/M) calculator requires human intervention. This feature is known to have trouble picking up different components of an office visit. Examples include:

  • An inability to distinguish between patient problems (current or historical) and family history
  • An inability to ascertain the difference between a patient diagnosis of DM, as in diabetes mellitus, or a prescription for Mucinex DM for a patient with DM

Like any tool, software can make a job more efficient, but only if it’s wielded by a skilled and knowledgeable operator.

Think Before You Buy

Another consideration that can muck up the works is using software that is outdated. Before purchasing coding edit software, do your research. Questions for your vendor include:

  • Is the software updated quarterly to reflect new National Correct Coding Initiative (NCCI) versions?
  • Is the software updated for Medicare medical necessity edits in a timely fashion?
  • Will the software be updated in time for the ICD-10 conversion?

In this ever-changing regulatory environment, software is only as good as its end users and its vendor support. Software that is misused or outdated is worse than none at all.


Angela Clements, CPC, CEMC, COSC, is an internal consultant in the Coding and Education Department at Ochsner Health Systems in New Orleans, with 15 years of healthcare experience in multi-specialty. She is a member of the AAPC National Advisory Board for Region 5 and member development officer of the Covington, La., local chapter.

Renee Dustman

Renee Dustman

Renee Dustman is executive editor at AAPC. She has a Bachelor of Science degree in Journalism and a long history of writing just about anything for just about every kind of publication there is or ever has been. She’s also worked in production management for print media, and continues to dabble in graphic design.
Renee Dustman

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Renee Dustman is executive editor at AAPC. She has a Bachelor of Science degree in Journalism and a long history of writing just about anything for just about every kind of publication there is or ever has been. She’s also worked in production management for print media, and continues to dabble in graphic design.

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