CMS Schizophrenia Audits Reveal Another Side Of Medical Coding

by  Find-A-Code™
May 4th, 2023

It is pretty easy for any medical coding specialist to use our website to find the proper codes for schizophrenia diagnosis and treatment. The codes are not hard to find if you know what you're looking for. But as a coding specialist yourself, how much do you know about the coding system beyond the knowledge that the work you do allows healthcare providers to bill insurance carriers and Medicare/Medicaid?

There is another side of medical coding that doesn't get talked about all that much. That other side is perfectly illustrated by the new CMS Minimum Data Set (MDS) audits for schizophrenia. Apparently, CMS has begun utilizing off-site audits to assess data set accuracy before launching official on-site audits. These new audits are based on the premise of self-reporting.

The Right Codes Are Important

CMS has taken the position that medical codes for schizophrenia are important enough to ensure medical facilities – particularly nursing homes and assisted living facilities – maintain the utmost accuracy in their record keeping. Should an MDS audit trigger an official on-site audit or lead to a facility self-reporting error, the facility's long-stay quality rating could be reduced to one star.

Why does that matter? Because a one-star rating can lead to some pretty negative consequences, including:

• a commensurate drop in a facility's overall rating
• being dropped from preferred networks
• facing scrutiny from industry stakeholders

According to the CMS, the external consequences of inaccurate data are less important than the internal impact. For example, incorrect medical codes could lead to improper diagnoses and treatment. A patient's health could be put at risk by an erroneous dataset.

CMS uses the rating system as a motivator to ensure medical codes and datasets are as accurate as they can be. When the correct codes are used, doctors are able to offer better care. That translates into better outcomes for patients.

Not Just a Billing Issue

It's easy to think of medical codes as nothing more than a billing tool. Indeed, that is why they were originally developed. Medical codes streamlined billing and made payments more efficient. But that was decades ago. These days, medical codes are more than just billing tools.

In the era of electronic health records, medical codes have become a vital tool for offering quality care across the entire spectrum of a patient’s interaction with the healthcare system. The same records are now seen by multiple clinicians. They are reviewed by multiple facilities. Everyone in the pipeline relies on accurate data to do what they do.

The CMS understands this. For better or worse, they understand that medical coding has become an indispensable means of sharing information among interested parties. And with that being the case, what started out as just a system to streamline billing now affects the actual care patients receive.

Always Strive for Accuracy

As a medical coding specialist, we encourage you to always strive for accuracy. Put in the time and effort necessary to get your codes right. And when you do make mistakes, own them. Then learn from them. The more accurate you are as a medical coder, the better the outcome for both your employer and the patients being served.

The codes for schizophrenia are important enough to the CMS that they are now utilizing on- and off-site audits to guarantee accurate datasets. When they find errors, they are not afraid to take action against a facility. That action can include a rating downgrade, a downgrade that is ultimately bad for a healthcare facility's business. Accuracy matters, both from a billing standpoint and in relation to patient health and outcomes.