Billing and coding incorrectly can cost your new independent practice, both financially and in terms of the time investment involved. Rejected claims must be recoded and resubmitted, which can seriously impact the continuity of your revenue stream. Coding errors can also be misconstrued as intentional or fraudulent, which can be even more detrimental to the success of your new practice. It’s critical to understand the most common coding problems – and to take steps to avoid them.
Compliance auditor Renee Dowling explains several coding issues in a recent interview:
- Not coding to the highest level of specificity. The person responsible for coding and billing should have a detailed understanding of the medical terminology for procedures and diagnoses.
- Missing or incorrect documentation. The provider must document the information properly for an accurate coding of the diagnosis or procedure. Taking advantage of electronic health record (EHR) technology for insurance claims can be helpful in this area.
- Lack of communication with the provider. When a claim is difficult to understand or the billing team member needs to clarify coding issues, the provider should be available to respond to those questions. Otherwise, less specific or unspecified codes could potentially lead to denials.
- Failing to use current or updated codes. Coders should review and understand the three principal coding sets established and updated annually by the World Health Organization (WHO) for ICD, the American Medical Association (AMA) for CPT, and the Centers for Medicare and Medicaid Services (CMS) for HCPCS.
- Undercoding and overcoding. Undercoding happens through oversight most of the time; however, some practices do so intentionally to avoid an audit. Overcoding results in a higher payment than warranted for the specific services provided, which can trigger an audit.
- Unbundling, or separately coding procedures that would usually be under one umbrella code. It’s important to check to see if multiple CPT codes can be billed together and to avoid unbundling, which may be viewed as false reporting in an attempt to earn a higher payout.
Using the right EHR for insurance claims can make the difference in your practice success.
The American Medical Association (AMA) lists some additional common mix-ups that you should avoid when coding:
- Upcoding, or reporting the highest-level evaluation-and-management (E/M) service regardless of the actual condition your patient presents with. While this isn’t always upcoding, you should accurately report the level of E/M code based on the patient’s condition and not just based on your practice’s specialty.
- Failing to check National Correct Coding Initiative (NCCI) edits when reporting multiple codes. CMS developed the NCCI to help ensure correct coding methods were followed and avoid inappropriate payments for Medicare Part B claims. If there is an NCCI edit, one of the codes is denied. NCCI edits will also typically provide a list of CPT modifiers available that may be used to override the denial. In certain cases, clear direction is stated that no modifier may be used to override the denial.
- Failing to append the appropriate modifiers or appending inappropriate modifiers. For example, this could involve reporting modifier 50, Bilateral Procedure, to a procedure code that already includes bilateral service.
- Overusing modifier 22, Increased Procedural Services. You must include proper documentation to explain why the procedure requires more work than usual.
- Improper reporting of the infusion and hydration codes, which are time-based. Good documentation of the start and stop times are essential for medical coders to properly bill for these services.
- Improper reporting of injection codes. Only report one code for the entire session during which the injections take place instead of multiple units of a code.
- Reporting unlisted codes without documentation. If you must use an unlisted code to properly bill for a service, you must properly document it.