Anuraag Srivastava
Medical coding mistakes is a common problem facing the healthcare industry, with around 50% of Medicare claims ending up inaccurate. Even a small error can lead to significant issues from claim denials to reduced reimbursements. If these errors persist, it can cause revenue loss, that's crucial for the growth of the industry. This blog takes a look at some of the common medical coding errors that could be avoided to decrease denials.
Upcoding and Downcoding
Upcoding can both be seen as fraud or abuse. It occurs when healthcare providers bill the patient for a costlier procedure than what was administered. For example, if you are a neurologist who looks into highly complex diseases, and choose to bill the patient for the highest level of service regardless of what the patient was treated for. This can happen due to misinterpretation, intentional fraud, or accidental error. This mistake could lead to severe financial penalties, if caught in audit, as it may be perceived as an attempt to overcharge patients.
Conversely, downcoding happens when a provider reports a lower-cost service than what was administered. This could potentially be due to a fear of audit or lack of proper documentation. While it does not attract financial penalties, it can lead to lower reimbursement rate, and a lower revenue than what was due.
There are several ways these mistakes can be tackled. For one, proper documentation would ensure that incorrect code isn’t applied while billing. Similarly, automated code-checking tools can be used to reduce the errors in this practice. Regular training of billing staff needs to be conducted to ensure they are well-versed with coding updates.
Incorrect use of modifier
Some healthcare providers might pick incorrect modifiers for the procedure they are billing for. Medical modifier is essentially a two-character code that provides additional information for a procedure or a medical condition for which the patient was diagnosed for, and is essential in determining the correct billing for the payment. Using incorrect modifiers can thus lead to incorrect reimbursement or even claim rejections.
Some of the common medical coding mistakes include using a modifier that does not match the service provided, failing to use a modifier at all when coding for a procedure, or applying multiple modifiers leading to claim rejections.
Apart from periodic updates and training the staff, healthcare organizations can maintain a documentation of modifiers commonly used by them to ensure that no errors occur while billing.
Mismatched diagnosis code and procedure code
While coding, each procedure code (CPT or HCPCS) is supported by a relevant diagnosis code (ICD-10) without fail. The idea behind having a diagnosis code is to ascertain whether correct diagnosis was used to reach the medical conclusion and justify the procedure that has been recommended. Failing to justify the diagnosis and the procedure could lead to claim denials.
There are other ways this error could occur. For instance, wrong diagnosis code could be accidentally used to justify a procedure, leading to incorrect denial of claim or reimbursement. The organization might completely miss adding an additional code in the form of a diagnosis code, and thus submit incorrect requests altogether.
Healthcare organizations can deploy medical coding software to check the diagnosis code associated with the procedure code. The providers can ensure that all diagnosis codes that are documented are clearly justified. One way of doing this is if they stay abreast with new changes and updates in ICD-10 and payer-specific coding policies.
Unbundling of codes
Complex medical coding design can lead to unbundling of codes. Providers might bill procedures separately when they should be grouped under a separate bundled code. There are many procedures that are part of comprehensive codes that cover multiple services or procedures under one code. Not billing them in the same way could lead to overcharging and compliance issues.
To avoid this, coders in healthcare organizations should be aware of CPT and HCPCS bundling rules. Using automated coding tools can also help resolve the problem - as it automatically assigns the bundled code correctly. Perform regular audits to ensure that nothing gets missed in the process.
Duplicate Billing
Sometimes, a provider or a healthcare entity might submit multiple bills for the same procedure. This could be due to multiple reasons. Apart from providers sending claims for a bundled procedure, a provider could have also submitted an existing claim without checking its status. This could be also due to lack of communication between providers or the departments that multiple claims were submitted.
By implementing a robust tracking system, providers can avoid submitting multiple claims. They can also develop a system where they review claims before submission to avoid duplicate entries. Educating the staff on duplicate claims scenarios could also help avoid this mistake.
Incomplete or inaccurate documentation
Common documentation errors could lead to underbilling, claim denials, or even legal issues. Accurate documentation is essential for correct coding. Some coding errors include incorrect patient information, missing physician signatures, or lack of details on the procedures performed. Implementing electronic health records and conducting regular audits are thus essential for correct documentation.
There are also cases where failure to verify patient information led to coding mistakes. This could include using incorrect insurance ID, failure to confirm coverage or medications, and submitting the claim to the wrong insurance provider. That’s why it is crucial that the front desk staff is trained to verify the insurance information of the patient effectively, before submitting the documentation to avoid these medical coding mistakes.
Lack of compliance with coding updates
Medical billing codes are frequently updated and failure to keep up with the changes could lead to incorrect claims. Some common mistakes include using outdated CPT, HCPCS, and ICD-10 codes, not adhering to payer-specific coding changes, and ignoring annual CMS and AMA coding updates.
One way to avoid this error is to subscribe to coding update newsletters and provide regular sessions on training on updated codes. Using technology that automates coding could help avoid any update error by default.
PCH Health: Your Medical Coding Solution
PCH Health is a leader in medical code services, that provides comprehensive services to avoid medical coding mistakes and ensures that less than 1% of the claims end up denied.
Having coded over 16 million claims, PCH Health has 1200+ credentialed coders spread across India, the Philippines, and the US. From identifying compliance changes to leveraging AI and rule-based engines and NLP for coding to ensuring regular audits, PCH Health is your go-to solution. Contact us to request a demo of our service.