The claim comes back with an ICD-10 rejection. The code looks familiar, the consultation was documented and the account seemed complete. Somewhere between the clinical record and the claim line, however, the information stopped matching.
In South Africa, ICD-10 is the national diagnostic coding standard. The code submitted should be supported by the healthcare record and used at the highest level of specificity the record allows. Small coding errors can be easy to miss and still delay payment.
1. Leaving the ICD-10 code off the claim
This is the simplest error and one of the easiest to prevent. If a required diagnosis code is missing from a claim line, the scheme may be unable to assess it. A pre-submission check should flag missing codes before the claim leaves the practice.
2. Choosing the wrong primary diagnosis
The primary diagnosis should represent the main condition responsible for the patient’s need for treatment or investigation during that episode of care. South African coding guidance allows only one primary diagnosis for the episode, followed by relevant secondary diagnoses.
Problems arise when a long-standing condition is automatically selected even though the patient was treated for something else, or when the sequence of codes does not reflect the consultation.
3. Coding without enough specificity
South African ICD-10 standards require codes to be used to the highest level of specificity supported by the clinical information. A broad or unspecified code may be appropriate when the record does not support anything more specific. It should not become the default simply because it is familiar.
The answer is better documentation, not guessing. Details such as site, laterality, type, severity or cause may affect the code, depending on the condition and applicable coding rules.
4. Adding detail that the clinical record does not support
More specific is only better when it is true and documented. A code should not imply a confirmed diagnosis, complication or degree of detail that does not appear in the record. Coding and clinical notes must tell the same story.
5. Omitting relevant secondary codes
Secondary diagnoses record additional conditions that affect patient care or coexist with the primary diagnosis in a way that matters to the episode. Leaving out a relevant secondary code can remove context that helps explain the services provided. Adding unrelated historical conditions can create a different problem, so each code should have a clear reason for being there.
6. Using a code that does not align with the service billed
A diagnosis code and a tariff or procedure code are assessed together. If the clinical reason on the claim does not reasonably support the service, the claim may be queried or rejected. This can happen when an old diagnosis is carried forward, the wrong visit template is used or the procedure line is copied without review.
7. Relying on outdated favourites or shortcut lists
Saved favourites can speed up capturing, but they still need review. Code sets, industry guidance and scheme rules can change. A shortcut that was correct when it was created may no longer be correct for the current patient or current claim.
8. Formatting or sequencing codes incorrectly
Electronic claims must follow the format expected by the relevant electronic standard and billing system. Punctuation, delimiters and the order of multiple diagnoses can matter. The South African standards state that sequence is used to infer which code is primary, so the order should be checked before submission.
How to improve coding accuracy in your practice
1. Document first, code second
Record the patient’s condition and the care provided clearly, as close to the consultation as possible. The person selecting the code should not have to reconstruct the encounter from a diary entry or memory several days later.
2. Build checks into the billing workflow
- Confirm that every required claim line has an ICD-10 code.
- Check that the primary diagnosis reflects the main reason for the episode of care.
- Use the highest level of specificity supported by the record.
- Review whether secondary codes are relevant and correctly sequenced.
- Check that the diagnosis supports the service or procedure billed.
- Investigate repeated rejection reasons and correct the source of the error.
3. Keep clinical and billing teams connected
A biller cannot code accurately when the clinical record is unclear, and a practitioner may not know which details are regularly missing unless the billing team feeds that information back. A short, regular review of recurring coding queries can improve both documentation and claims performance.
4. Use the rejection as useful data
When a claim is rejected for an ICD-10 reason, record the exact reason and the correction made. Over time, this shows whether the issue is linked to a particular template, service, user or workflow. That is far more useful than correcting the same error one claim at a time.
ICD-10 coding sits between the clinical record and the financial record of the practice. A consistent process keeps those two records aligned and gives the team a clearer place to start when a claim comes back.
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