Medical billers and coders are very important figures in the healthcare business. They keep the physicians, nurses, healthcare professionals, and patients organized and on track with their duties and treatment by keeping record of all the diagnosis periods, treatments, and procedures.
They submit the insurance claims to the insurance agencies as well, which turns into reimbursement for the healthcare organization. In short, they are heroes in the medical industry who do not wear capes but enable medical facilities to continue to survive with revenue capture. However, if a medical biller or a coder makes an error, it might delay the claim or even get it refused. Mistakes from them will not only slow down the revenue cycle but could potentially affect the survival of the medical practice and even patients’ wellbeing.
Recent audits by the private insurers and the government have shown a multitude of unfortunate cases of fraudulent or abusive medical billing and coding practices.
While the coders and billers deserve appreciation for the work they do, it is important for them to say no to illegal medical billing practices and to stay away from any kind of legal troubles. Otherwise, they could get their license suspended along with the healthcare provider.
Medical coding and billing errors basically fall into two main categories: ‘Abuse’ and ‘Fraud’. Fraud is the intentional wrong use of your power or a deliberate misrepresentation of the claims and codes you are submitting. It is unethical and illegal. Abuse, on the other hand, means that the falsification was an innocent mistake by the coder or biller due to ignorance or failure to practice normative coding rules, but this is still nonetheless representative of the medical practice.
Regardless of if your mistake has fallen under the category of fraud or abuse, the consequences are costly and difficult to deal with.
Mistakes to avoid in medical coding
With such a vast number of CPT codes, plus modifiers and particular payer rules, one can unintentionally select the incorrect code for the procedure/treatment when completing the claim or filling the documentation. Here are some of the mistakes you should definitely avoid while practicing medical billing or coding in the field:
Unbundling codes
Simply put, unbundling is using multiple CPT codes for multiple constituents of a medical procedure or treatment when a single code could have been used to cover all the constituents of the surgery, treatment, or medical procedure.
Many billers and coders go for unbundling codes because the medical providers get a higher payout. However, this practice is considered illegal, unethical, and falls under the category of ‘fraud’. Single codes should be used to catch all the constituents whenever available.
Upcoding
Upcoding usually happens in scenarios such as when a healthcare provider visits a patient for just a few minutes but the coder or biller files a claim for a, for example, full 45-minutes medical examination.
The consequences and the outcomes of making an upcoding mistake could be severe and heavy on the pocket. For example, recently a psychiatrist was fined $400,000 for upcoding 10 minute medication refill appointments to fill session 50 minute appointments.
Not checking the National Correct Coding Initiative upgrades when filing multiple codes at a time
The Medicaid and Medicare services created the NCCI (National Correct Coding Initiative) to ensure that all protocols of proper coding were followed. This initiative was put forward to avoid the inappropriate payments from the insurance agencies for patients’ treatments. Failure to check updates and edits will result in denials due to ignorance of the changes necessary for claim acceptance.
Overusing the procedural services modifier-22
Modifier-22 for procedural services enables coders to report if any procedures had more work required than usual. However, the coders and billers must include correct documentation that explains why the specific treatment or procedure required more work than any other ordinary one.
Reporting the unlisted codes without appropriate documentation for proof
The unlisted code must be reported with proper proof-bearing documentation. For proper billing, it is necessary to back the unlisted codes with real documentation by the provider regarding the patient.
Filing the intramuscular injection codes incorrectly
Using multiple codes for a single injection is inappropriate. CPT code 96372 should be reported for each individual IM injection performed with modifier 59 appended to any subsequent injection codes listed on a claim form. This code is reported per injection even if multiple substances are in a single injection.
Outsourcing professional medical coding services for your medical practice could help you avoid these common coding mistakes. Not only does it reduce the practice compliance and audit risk, but it also improves your revenue cycle.