The care you deliver has value, and accurate medical coding ensures your practice gets paid for it. Yet, even a small medical coding error can jeopardize reimbursement, triggering claim denials, reimbursement delays, and revenue loss.
Coding and billing errors drain a staggering $125 billion annually in the United States alone! The impact is felt across the healthcare system, from medical practitioners like you to the patients you serve.
Billing mistakes aren’t about dollars and cents; they can tarnish your credibility and erode patient trust. Let’s explore the nuances of medical coding and uncover strategies to prevent coding errors.
Medical Coding & Billing Errors that Drain Your Revenue
The recent Experian survey reports that denials are rising, primarily due to claim errors.
Here are 8 common medical coding errors you should avoid when submitting claims.
1. Unbundling codes
Unbundling involves submitting multiple codes for various parts of a procedure that should be billed under a single code. This can artificially inflate the reimbursement amount and lead to non-compliance.
For example, consider a scenario where a physician orders a comprehensive blood test for a patient. The practice should use a single billing code to encompass all the blood tests performed.
Unbundling occurs when a practice bills each test separately using different codes, instead of a comprehensive bundled code that covers them.
2. Overcoding/Undercoding
Overcoding and undercoding, or upcoding and downcoding, are common pitfalls in medical billing.
Overcoding occurs when a healthcare provider codes for a higher service or procedure than what was delivered. This increases reimbursement, but when done deliberately, it signals fraudulent activity.
Conversely, undercoding occurs when a provider uses a lower-level code that doesn’t accurately capture the intricacy or intensity of the services delivered, resulting in lower reimbursements.
Although overcoding and undercoding differ, both result in billing discrepancies, erode patient trust, and expose practices to regulatory penalties.
3. Inaccurate Coding
Errors in selecting the correct CPT (Current Procedural Terminology) or HCPCS (Healthcare Common Procedure Coding System) codes can result in inaccurate billing.
Given the extensive collection of ICD-10 codes and the frequent updates by CMS, it is imperative for both seasoned and novice coders to undergo ongoing training to stay compliant.
4. Neglecting NCCI Edits for Multiple Codes
The Centers for Medicare & Medicaid Services (CMS) developed the National Correct Coding Initiative (NCCI) to ensure accurate coding and prevent incorrect payments within Medicare Part B claims.
NCCI edits are sets of rules that identify code pairs or groups that typically should not be billed together for the same patient on the same day by the same provider. When the system identifies an NCCI edit, it declines one of the codes.
Scrutinizing NCCI edits when presenting multiple codes in a claim is pivotal. Understanding how to evaluate high-risk patients treated by the same provider on the same day helps prevent denials and ensure accurate compensation for Medicare Part B claims.
5. Duplicate Billing
Duplicate billing occurs when you bill the same medical service or procedure more than once for a single patient during the same visit or treatment period.
Duplicate billing often stems from administrative oversights or technical glitches in the billing system, which results in overpayment. Healthcare organizations should implement robust billing procedures to prevent such errors. Regular audits of billing records help identify and correct billing errors before they lead to financial discrepancies or patient dissatisfaction.
6. Inappropriate Modifier Application with Inadequate Documentation
Inaccurate CPT modifier usage is another common reason for coding errors. The American Medical Association (AMA) has flagged the frequent misuse of modifier 22, which denotes a more complex procedure, often due to insufficient supporting documentation. Similarly, insurance carriers have highlighted errors in modifiers 25, 50, and 59, indicating instances where they are employed inappropriately.
Provide comprehensive documentation that justifies the reasons for the procedure’s heightened complexity to prevent denials. For example, consider the situation where a lesion removal on an obese patient becomes more challenging due to their weight. Adding modifier 22 can accurately communicate the increased difficulty.
Inadequate or unclear documentation can cause miscoding and lead to claim rejection or denial. Comprehensive documentation and prompt response to provider queries ensure accurate coding and appropriate reimbursement.
7. Improper Code Usage
Accurate documentation of medical services, with precise start and end times, is pivotal for coders to ensure proper billing procedures. However, complications arise when services span two consecutive days, demanding distinct coding strategies.
For example, consider a patient receiving intravenous hydration continuously from 11 p.m. to 2 a.m. Rather than automatically reporting a single infusion code, coders must select the appropriate CPT code based on the service provided and applicable coding guidelines. Note that CPT 96374 describes an initial intravenous push, while CPT 96376 applies to repeat intravenous pushes of the same substance under specific circumstances. Neither code represents continuous hydration infusion.
To ensure accurate coding, report only a single code for an entire session during which injections occur. Never report multiple units of the same code; it leads to erroneous billing.
8. Using Unlisted Codes without Proper Documentation
Billing unlisted codes without proper documentation poses a significant coding challenge.
When no existing code accurately represents a service, you may need an unlisted code. In such cases, meticulous documentation is imperative to justify the code and support appropriate reimbursement.
However, using these codes without comprehensive documentation explaining the service, its complexity, and the reasons for using the unlisted code leads to billing disputes, claim denials, and compliance issues. Healthcare providers should ensure each unlisted code billed is accompanied by detailed documentation that elucidates the unique aspects of the service and reinforces the necessity.
Mitigate Billing Errors and Boost Revenue
The goal of claim submission is to secure accurate, timely reimbursement, and clean claims increase the likelihood of achieving this. At Glenwood Systems, we leverage AI in verification, documentation, and denial management. GlaceEMR & GlaceRCM, our advanced practice management tools, learn from past denial cases and efficiently resolve denials, boosting your revenue. We diligently track each claim until it’s fully resolved without prematurely removing it from A/R (accounts receivable) based on a predefined time frame.
Want stress-free revenue cycle management? Let’s partner and make it happen.